Healthcare Provider Details

I. General information

NPI: 1346626041
Provider Name (Legal Business Name): BRIAN RANDOLPH DYSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE
OLYMPIA FIELDS IL
60461
US

IV. Provider business mailing address

20201 CRAWFORD AVE
OLYMPIA FIELDS IL
60461-1010
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-4000
  • Fax: 708-503-3241
Mailing address:
  • Phone: 708-747-4000
  • Fax: 708-503-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberED0500
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: