Individual
DR. HERMAN JUSTIS DICK JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2204 EASTLAND DR, BLOOMINGTON, IL 61704-3566
(309) 662-9461
(309) 663-0222
Mailing address
2204 EASTLAND DR, BLOOMINGTON, IL 61704-3566
(309) 662-9461
(309) 663-0222
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
036056374
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036056374
—
IL
01
—
130005238
MEDICARE ID
IL
01
—
5715381
BLUE CROSS BLUE SHIELD
IL
Enumeration date
09/15/2006
Last updated
05/21/2008
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