Healthcare Provider Details

I. General information

NPI: 1588713374
Provider Name (Legal Business Name): BRUCE C CORWIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15728 S ROUTE 59
PLAINFIELD IL
60544-2693
US

IV. Provider business mailing address

15728 S ROUTE 59
PLAINFIELD IL
60544-2693
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-8831
  • Fax: 815-436-6863
Mailing address:
  • Phone: 815-436-8831
  • Fax: 815-436-6863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036068055
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier399980
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE GROUP PTAN
# 2
Identifier036068055
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: