Provider Demographics
NPI:1760431712
Name:MCLEAN COUNTY NEUROLOGY SC
Entity Type:Organization
Organization Name:MCLEAN COUNTY NEUROLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:JUSTUS
Authorized Official - Last Name:DICK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:309-662-9461
Mailing Address - Street 1:2204 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3566
Mailing Address - Country:US
Mailing Address - Phone:309-662-9461
Mailing Address - Fax:
Practice Address - Street 1:2204 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3566
Practice Address - Country:US
Practice Address - Phone:309-662-9461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF6543OtherMEDID
IL5715381OtherBLUE CROSS BLUE SHIELD
IL650050Medicare PIN