Healthcare Provider Details

I. General information

NPI: 1962517656
Provider Name (Legal Business Name): BRIAN K. DAINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 LINCOLN DRIVE
HERRIN IL
62948
US

IV. Provider business mailing address

510 LINCOLN DRIVE
HERRIN IL
62948
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-6800
  • Fax: 618-997-1187
Mailing address:
  • Phone: 618-997-6800
  • Fax: 618-997-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberML20008529
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036.131162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: