Basic Information
| Provider Information | |||||||||
| NPI: | 1881643948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSBOROUGH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1614 E NORRIS DR | ||||||||
| Address2: | |||||||||
| City: | OTTAWA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613503681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154331010 | ||||||||
| FaxNumber: | 8154330067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1614 E NORRIS DR | ||||||||
| Address2: | |||||||||
| City: | OTTAWA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613503681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154331010 | ||||||||
| FaxNumber: | 8154330067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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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 | 207Q00000X | 036-074039 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015533 | 01 | HEALTH ALLIANCE | OTHER | 036074039 | 05 | IL | MEDICAID |