Healthcare Provider Details

I. General information

NPI: 1659454742
Provider Name (Legal Business Name): GWENDOLYN G BRUMBAUGH APN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

IV. Provider business mailing address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-4366
  • Fax: 773-521-0537
Mailing address:
  • Phone: 773-484-4366
  • Fax: 773-521-0537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209.003177
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number041-227109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: