Basic Information
| Provider Information | |||||||||
| NPI: | 1013982099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR | ||||||||
| Address2: | SUITE 1787 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606751787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307854343 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3825 HIGHLAND AVE | ||||||||
| Address2: | TOWER 2 - SUITE 400 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307194799 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD417581 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 036-120806 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036120806 | 05 | IL | MEDICAID |