Basic Information
| Provider Information | |||||||||
| NPI: | 1194091991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | MB, BCH, BAO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 N OAK ST | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308568900 | ||||||||
| FaxNumber: | 6308568933 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 N OAK ST | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308568900 | ||||||||
| FaxNumber: | 6308568933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 125.062127 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | 125062127 | IL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.