Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | IL |
NPI | 1164468724 |
---|---|
Provider Name | Dr. Eric Wernsman |
First Address | Bloomington, IL 61704-6301 |
Second Address | Normal, IL 61761 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036093245-5 | (05) | IL |
05721369 | BC/BS (01) | IL |
G23676 | (02) | IL |