Healthcare Provider Details

I. General information

NPI: 1013982099
Provider Name (Legal Business Name): KENNETH P. BRIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/28/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 E PEARSON ST APT 6201
CHICAGO IL
60611-2191
US

IV. Provider business mailing address

180 E PEARSON ST APT 6201
CHICAGO IL
60611-2191
US

V. Phone/Fax

Practice location:
  • Phone: 630-719-4799
  • Fax:
Mailing address:
  • Phone: 630-310-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-120806
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: