Healthcare Provider Details

I. General information

NPI: 1104506153
Provider Name (Legal Business Name): BRENDAN NAMOFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S MAPLE AVE
OAK PARK IL
60304-1091
US

IV. Provider business mailing address

1250 S INDIANA AVE APT 505
CHICAGO IL
60605-3224
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 708-278-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number146796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: