Provider Demographics
NPI:1083613327
Name:BLOOMINGTON NORMAL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BLOOMINGTON NORMAL HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:KULB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-834-4000
Mailing Address - Street 1:2100 FORT JESSE RD
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9370
Mailing Address - Country:US
Mailing Address - Phone:309-834-4000
Mailing Address - Fax:309-834-4007
Practice Address - Street 1:2100 FORT JESSE RD
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9370
Practice Address - Country:US
Practice Address - Phone:309-834-4000
Practice Address - Fax:309-834-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002512261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50181OtherBCBS
IL=========001Medicaid
IL50181OtherBCBS