Healthcare Provider Details

I. General information

NPI: 1629553748
Provider Name (Legal Business Name): MALCOLM BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 N LECLAIRE AVE
CHICAGO IL
60644-3413
US

IV. Provider business mailing address

176 N LECLAIRE AVE
CHICAGO IL
60644-3413
US

V. Phone/Fax

Practice location:
  • Phone: 773-688-5299
  • Fax:
Mailing address:
  • Phone: 773-688-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberA-2256-0001-A
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA-2256-0001-A
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: