Provider Demographics
NPI:1346333689
Name:NORD, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:NORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-6344
Mailing Address - Country:US
Mailing Address - Phone:309-829-9975
Mailing Address - Fax:
Practice Address - Street 1:308 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:309-663-5050
Practice Address - Fax:309-663-3401
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054760173000000X, 207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054760Medicaid
IL080016047Medicare ID - Type UnspecifiedRR INDIVIDUAL #
ILD14101Medicare UPIN
IL961850Medicare ID - Type UnspecifiedGROUP #
IL036054760Medicaid
IL633440Medicare ID - Type UnspecifiedINDIVIDUAL #