Healthcare Provider Details

I. General information

NPI: 1457355315
Provider Name (Legal Business Name): ROBERT JUDSON BREWER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S PARK AVE 3RD FLOOR
HERRIN IL
62948-3612
US

IV. Provider business mailing address

PO BOX 1105
INDIANAPOLIS IN
46206-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-2002
  • Fax: 618-351-6497
Mailing address:
  • Phone: 618-549-5361
  • Fax: 618-549-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23499
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036117928
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: