Healthcare Provider Details

I. General information

NPI: 1962723981
Provider Name (Legal Business Name): KATRICE MARIE BROOKS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19310 S HALSTED ST
GLENWOOD IL
60425-1562
US

IV. Provider business mailing address

19310 S HALSTED ST
GLENWOOD IL
60425-1562
US

V. Phone/Fax

Practice location:
  • Phone: 708-300-3132
  • Fax: 773-790-4034
Mailing address:
  • Phone: 708-300-3132
  • Fax: 773-790-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61357-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036158316
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: