Healthcare Provider Details

I. General information

NPI: 1629181284
Provider Name (Legal Business Name): DEERBROOK MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 W WINCHESTER RD STE 112
LIBERTYVILLE IL
60048-5365
US

IV. Provider business mailing address

1870 W WINCHESTER RD STE 112
LIBERTYVILLE IL
60048-5365
US

V. Phone/Fax

Practice location:
  • Phone: 847-224-0165
  • Fax: 847-247-2840
Mailing address:
  • Phone: 847-224-0165
  • Fax: 847-247-2840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number36058893
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085001035
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36110464
License Number StateIL

VIII. Authorized Official

Name: DR. IRA FENTON
Title or Position: OWNER
Credential: DO
Phone: 847-367-7340