Healthcare Provider Details

I. General information

NPI: 1205911237
Provider Name (Legal Business Name): HEIDI SHARON BROOKENTHAL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 S KING DR
CHICAGO IL
60616-4746
US

IV. Provider business mailing address

2535 S KING DR
CHICAGO IL
60616-4746
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7960
  • Fax: 708-503-3993
Mailing address:
  • Phone: 312-842-7117
  • Fax: 708-503-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036103288
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: