Healthcare Provider Details

I. General information

NPI: 1235182809
Provider Name (Legal Business Name): BRIAN LEE ATWOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N EAST ST
OLNEY IL
62450-2426
US

IV. Provider business mailing address

1400 N EAST ST
OLNEY IL
62450-2426
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-1400
  • Fax: 618-395-1405
Mailing address:
  • Phone: 618-395-1400
  • Fax: 618-395-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-110096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: