Provider Demographics
NPI:1053506352
Name:BLOOMINGTON PEDIATRICS AND ALLERGY LTD
Entity Type:Organization
Organization Name:BLOOMINGTON PEDIATRICS AND ALLERGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:LABOUNTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-663-2354
Mailing Address - Street 1:306 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3506
Mailing Address - Country:US
Mailing Address - Phone:309-663-2354
Mailing Address - Fax:309-662-8602
Practice Address - Street 1:306 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3506
Practice Address - Country:US
Practice Address - Phone:309-663-2354
Practice Address - Fax:309-662-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058820Medicaid
IL036075395Medicaid
IL036090475Medicaid
IL036115725Medicaid
IL036094964Medicaid
IL036060449Medicaid
IL036078523Medicaid
IL036097491Medicaid