Provider Demographics
NPI:1942592118
Name:HEART OF ILLINOIS OBSTETRICS AND GYNECOLOGY, S.C.
Entity Type:Organization
Organization Name:HEART OF ILLINOIS OBSTETRICS AND GYNECOLOGY, S.C.
Other - Org Name:HAROLD A. NORD OBSTETRICS AND GYNECOLOGY, S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:GEORGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-838-6748
Mailing Address - Street 1:1505 EASTLAND DR STE 2200
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7910
Mailing Address - Country:US
Mailing Address - Phone:309-454-3456
Mailing Address - Fax:309-454-6977
Practice Address - Street 1:1505 EASTLAND DR STE 2200
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7910
Practice Address - Country:US
Practice Address - Phone:309-454-3456
Practice Address - Fax:309-454-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068939207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
004750OtherHEALTH ALLIANCE
1548206519OtherHAROLD NORD INDIVIDUAL NPI
1750321667OtherGENEVA A. PETERSEN NPI
IL036068939Medicaid
IL1255700316OtherABIGAIL CERVANTES NPI
557210OtherMEDICARE PTAN
004750OtherHEALTH ALLIANCE
1750321667OtherGENEVA A. PETERSEN NPI