Provider Demographics
NPI:1841229507
Name:BLOOMINGTON MEDICAL LABORATORY PHYSICIANS, S.C.
Entity Type:Organization
Organization Name:BLOOMINGTON MEDICAL LABORATORY PHYSICIANS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOYCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-288-8325
Mailing Address - Street 1:PO BOX 9518
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9518
Mailing Address - Country:US
Mailing Address - Phone:309-663-2237
Mailing Address - Fax:
Practice Address - Street 1:2200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4364
Practice Address - Country:US
Practice Address - Phone:309-663-2237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC1703OtherRAILROAD MEDICARE
IL05719553OtherBLUE CROSS BLUE SHIELD
IL05719553OtherBLUE CROSS BLUE SHIELD