Provider Demographics
NPI:1639508567
Name:THE BLEEDING AND CLOTTING DISORDERS INSTITUTE
Entity Type:Organization
Organization Name:THE BLEEDING AND CLOTTING DISORDERS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TARANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-5337
Mailing Address - Street 1:427 W NORTHMOOR RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3542
Mailing Address - Country:US
Mailing Address - Phone:309-692-5337
Mailing Address - Fax:309-693-3913
Practice Address - Street 1:427 W NORTHMOOR RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3542
Practice Address - Country:US
Practice Address - Phone:309-692-5337
Practice Address - Fax:309-693-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-01
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0177183336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL398680716Medicaid
7225372OtherBCBS OF IL
P00096725OtherRAILROAD MEDICARE
ILE96359Medicare UPIN
IL561680Medicare PIN