Healthcare Provider Details

I. General information

NPI: 1366880908
Provider Name (Legal Business Name): STACY SUZANNE BROWN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 N CALIFORNIA AVE STE 635; 645
CHICAGO IL
60625-3645
US

IV. Provider business mailing address

2740 W FOSTER AVE STE 310
CHICAGO IL
60625-3547
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax: 773-878-0788
Mailing address:
  • Phone: 773-878-8200
  • Fax: 773-293-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036.139462
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: