Provider Demographics
NPI:1487731220
Name:BROMENN PHYSICIANS MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:BROMENN PHYSICIANS MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-268-2129
Mailing Address - Street 1:115 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1516
Mailing Address - Country:US
Mailing Address - Phone:815-692-2305
Mailing Address - Fax:
Practice Address - Street 1:115 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1516
Practice Address - Country:US
Practice Address - Phone:815-692-2305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL143970Medicare Oscar/Certification