Basic Information
| Provider Information | |||||||||
| NPI: | 1457355315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | JUDSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1105 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 S PARK AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629483612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422002 | ||||||||
| FaxNumber: | 6183516497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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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 | 208600000X | 23499 | KY | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 036117928 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7210895 | 01 | IL | AETNA | OTHER | 036117928 | 05 | IL | MEDICAID | 3932056 | 01 | IL | BCBS | OTHER | 654532 | 01 | IL | HEALTHLINK | OTHER | 133018 | 01 | IL | HEALTH ALLIANCE | OTHER | 319226 | 01 | IL | GHP | OTHER | 64234990 | 05 | KY | MEDICAID |