Basic Information
| Provider Information | |||||||||
| NPI: | 1750892766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TWIN CITIES MEDICAL EQUIPMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3107 FIONA WAY | ||||||||
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| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617047011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098250797 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN | ||||||||
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| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 10/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | NEWCOMER | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3098250797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 036078056 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.