Basic Information
| Provider Information | |||||||||
| NPI: | 1548367535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | JENCARE NEIGHBORHOOD MEDICAL CENTER SOUTH CHICAGO, LLC | ||||||||
| Address2: | 2231 E. 95TH STREET | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL - ILLINOIS | ||||||||
| PostalCode: | 60617 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 7737687700 | ||||||||
| FaxNumber: | 3122769660 | ||||||||
| Practice Location | |||||||||
| Address1: | 19310 S HALSTED ST | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604251562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083003132 | ||||||||
| FaxNumber: | 7737904034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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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 | 213ES0103X | 016004793 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016004793 | 05 | IL | MEDICAID | 0001621735 | 01 | IL | BCBS | OTHER | 7552001 | 01 | IL | PTAN | OTHER | P00245960 | 01 | IL | RAILROAD MEDICARE | OTHER |