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General NPI Number Information
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NPI Number | 1548408057
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Entity Type | Individual
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Provider Name | DWAIN CLARK ILLMAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/22/2009
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 811 W 2ND ST
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City | BLOOMINGTON
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State | IN
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Zip | 47403-2251
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Country | US
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Telephone | 812-353-3533
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Fax | 812-353-3204
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Provider Business Mailing Address
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Address Line | PO BOX 2568
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City | BLOOMINGTON
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State | IN
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Zip | 47402-2568
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Country | US
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Telephone | 812-353-3533
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Fax | 812-353-3202
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 01027208
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License Number State | IN
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