Basic Information
| Provider Information | |||||||||
| NPI: | 1104442615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARLE BROMENN MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROMENN FAMILY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1304 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617613558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 FRANKLIN AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617613676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094541400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2020 | ||||||||
| LastUpdateDate: | 06/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | ARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3092682410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.