Healthcare Provider Details

I. General information

NPI: 1356442347
Provider Name (Legal Business Name): BRENDA K. FANN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 OGDEN AVE SUITE 330
AURORA IL
60504-5894
US

IV. Provider business mailing address

2020 OGDEN AVE STE 330
AURORA IL
60504-5897
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-4850
  • Fax: 630-978-6865
Mailing address:
  • Phone: 630-978-4850
  • Fax: 630-978-6865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036100490
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036100490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: