Healthcare Provider Details

I. General information

NPI: 1710541206
Provider Name (Legal Business Name): BRANDON ALEXANDER WHEATLEY MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVENUE ROOM A700 - MC 7082
CHICAGO IL
60637
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-4503
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1447
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number62051
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62051
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.083226
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: