Provider Demographics
NPI:1376571844
Name:NILLES, JOEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:
Last Name:NILLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5652
Mailing Address - Country:US
Mailing Address - Phone:309-310-3994
Mailing Address - Fax:
Practice Address - Street 1:VIRGINIA & FRANKLIN STREETS
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-827-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099319207Q00000X
IL036-099319207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099319-1Medicaid
IL05721369OtherBC/BS
IL036099319-1Medicaid
ILK19622Medicare ID - Type Unspecified