Healthcare Provider Details

I. General information

NPI: 1265062178
Provider Name (Legal Business Name): JON ELLIOTT DALE BRUBAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W LOSEY ST
SCOTT AFB IL
62225-5250
US

IV. Provider business mailing address

310 W LOSEY ST
SCOTT AFB IL
62225-5250
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-9355
  • Fax: 618-256-7629
Mailing address:
  • Phone: 618-256-9355
  • Fax: 618-256-7629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036.165622
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.165622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: