Provider Demographics
NPI:1225061393
Name:BROMENN PHYSICIAN MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BROMENN PHYSICIAN MANAGEMENT CORPORATION
Other - Org Name:ILLINOIS HEART & LUNG ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PHYSICIANS MGMNT CORP
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-268-2129
Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:SUITE 4500
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-828-1166
Mailing Address - Fax:309-862-0330
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:SUITE 4500
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-828-1166
Practice Address - Fax:309-862-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212636OtherMEDICARE GROUP NUMBER
IL05732097OtherBCBS GROUP NUMBER
IL05732097OtherBCBS GROUP NUMBER