Basic Information
Provider Information | |||||||||
NPI: | 1871637454 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRUCE A. BROWN, M.D., S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 222 | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 600150222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474050654 | ||||||||
FaxNumber: | 8474050658 | ||||||||
Practice Location | |||||||||
Address1: | 6440 GRAND AVE | ||||||||
Address2: | SUITE 206 | ||||||||
City: | GURNEE | ||||||||
State: | IL | ||||||||
PostalCode: | 600315257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8477828349 | ||||||||
FaxNumber: | 8477828546 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/16/2007 | ||||||||
LastUpdateDate: | 10/29/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | BRUCE | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 8477828349 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 04921836 | 01 |   | BLUE CROSS BLUR SHIELD | OTHER |