Basic Information
| Provider Information | |||||||||
| NPI: | 1912923269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3183 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084920502 | ||||||||
| FaxNumber: | 7084920565 | ||||||||
| Practice Location | |||||||||
| Address1: | 6440 GRAND AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600315257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477828349 | ||||||||
| FaxNumber: | 8477828546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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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 | 208800000X | 036090508 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 214706 | 01 | IL | MEDICARE | OTHER | DE5300 | 01 | IL | MEDICARE | OTHER | 036090508 | 05 | IL | MEDICAID | 1518027812 | 01 | IL | NPI | OTHER | R00709 | 01 | IL | MEDICARE | OTHER | 01635877 | 01 | IL | BCBS | OTHER | 04921836 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 212210 | 01 | IL | MEDICARE | OTHER |