Healthcare Provider Details

I. General information

NPI: 1154387850
Provider Name (Legal Business Name): BRETT PRYWITCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 06/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 STATE ST CHESTER MEMORIAL HOSPITAL
CHESTER IL
62233-1116
US

IV. Provider business mailing address

1715 DEER TRACKS TRL STE 130
SAINT LOUIS MO
63131-1839
US

V. Phone/Fax

Practice location:
  • Phone: 618-826-4581
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD466600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: