Provider Demographics
NPI:1134308620
Name:KENT S TAULBEE MD SC
Entity Type:Organization
Organization Name:KENT S TAULBEE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAULBEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-663-6386
Mailing Address - Street 1:2418 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5915
Mailing Address - Country:US
Mailing Address - Phone:309-663-6386
Mailing Address - Fax:309-662-7622
Practice Address - Street 1:2418 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5915
Practice Address - Country:US
Practice Address - Phone:309-663-6386
Practice Address - Fax:309-662-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5700247OtherBLUE CROSS BLUE SHIELD
IL647720Medicare PIN
ILC44768Medicare UPIN