Healthcare Provider Details

I. General information

NPI: 1982016325
Provider Name (Legal Business Name): BRANDON C JOHN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 25TH AVE
BELLWOOD IL
60104-1961
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 708-467-7254
  • Fax:
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: