Bloomington Normal Healthcare, LLC
Organization Active NPI Ambulatory Surgical Clinic/Center · Normal, IL
NPI 1083613327 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1083613327
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Ambulatory Surgical Clinic/Center 261QA1903X
- License
- 7002512 (IL)
- Legal business name
- BLOOMINGTON NORMAL HEALTHCARE, LLC
- Practice address
- 2100 Fort Jesse Rd
Normal, IL 61761-9370 - Phone
- (309) 834-4000
- Fax
- (309) 834-4007
- NPI assigned
- Jul 19, 2005
- Organization subpart
- No
Authorized official
- Name
- Dr. Thomas B Kulb, MD
- Title
- Physician/Owner
- Phone
- (309) 834-4000
Member of 2
Practitioners 3
-
Omar S Khokhar, MD
-
Vicken S Chalian, M.D.
-
Travis Holt, M.D.
Medicare Care Compare: Ambulatory surgical center
- Listed as
- Bloomington Normal Healthcare LLC
- Medicare certification status
- Terminated Voluntary: merger or closure, Dec 1, 2023
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 14D0991589 | Bloomington Normal Healthcare Surgery Center | Certificate of waiver | Sep 24, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20241227001278 | IL | Part B Supplier - Ambulatory Surgical Center | 1153503958 | Practice locations: Normal, IL |
National Provider Directory
Locations
2100 Fort Jesse Rd
Normal, IL 61761
Phone (309) 531-6131
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ambulatory Surgical Clinic/Center | 261QA1903X | 7002512 | IL | Yes |
Addresses
Primary practice location
2100 Fort Jesse Rd
Normal, IL 61761-9370
Mailing address
2100 Fort Jesse Rd
Normal, IL 61761-9370
Phone (309) 834-4000
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 50181 | Other | IL | BCBS |
Other providers in Normal, IL
- Tyler Curtis Bishop
- Sue Ann Blankenship
- Alexa Blatt
- Mackenzie Blomquist
- Bloomington Heart Institute
- Bloomington Normal Public Transportation System
- Bloomington Perfusionist Inc.
- Bloomington Radiology S C
- Bloomington-Normal Treatment Center, LLC
- Blue Skies Counseling LLC
All providers in Normal, IL · Ambulatory Surgical Clinic/Center in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.