Provider Demographics
NPI:1114038528
Name:BLOOMINGTON NORMAL EAR NOSE THROAT LTD
Entity Type:Organization
Organization Name:BLOOMINGTON NORMAL EAR NOSE THROAT LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLIMKEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-662-3277
Mailing Address - Street 1:1404 EASTLAND DR STE 209
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7904
Mailing Address - Country:US
Mailing Address - Phone:306-662-3277
Mailing Address - Fax:309-663-0845
Practice Address - Street 1:1404 EASTLAND DR STE 209
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7904
Practice Address - Country:US
Practice Address - Phone:306-662-3277
Practice Address - Fax:309-663-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732023OtherBC/BS AUDIOLOGY
05700224OtherBLUE CROSS/BLUE SHIELD
IL330606647-001OtherAUDIOLOGY
=========OtherFEIN
IL330606647-001OtherAUDIOLOGY
222590Medicare ID - Type UnspecifiedDR. OCHELTREE
215876Medicare PIN
C37824Medicare UPIN
341330Medicare ID - Type UnspecifiedDR. RUSSELL