Basic Information
| Provider Information | |||||||||
| NPI: | 1053932236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UFERT | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 405 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6185290449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2020 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN184161 | AZ | N | Nursing Service Providers | Registered Nurse | 163W00000X | 2012007845 | MO | N | Nursing Service Providers | Registered Nurse | 367500000X | 209022763 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 214881 | 01 | IL | MULTISPECIALTY GROUP PTAN | OTHER |