Healthcare Provider Details

I. General information

NPI: 1316928864
Provider Name (Legal Business Name): CHARLES MARK BRAVERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5057 SHORELINE RD
LAKE BARRINGTON IL
60010-1700
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-5005
  • Fax: 847-381-5036
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036077877
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: