Healthcare Provider Details

I. General information

NPI: 1417497165
Provider Name (Legal Business Name): JOSEPH ANTHONY BRISBOIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 LINCOLN HWY
MOKENA IL
60448
US

IV. Provider business mailing address

110 WESTVIEW ST
HOFFMAN ESTATES IL
60169-3054
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-2171
  • Fax:
Mailing address:
  • Phone: 331-645-9133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: