Healthcare Provider Details

I. General information

NPI: 1134466485
Provider Name (Legal Business Name): COREY AUSTIN BROOKS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 04/21/2025
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 CROSS ST DIV IM MEDICAL ONCOLOGY, STE 180
SHILOH IL
62269-2914
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 618-607-1340
  • Fax: 618-622-9724
Mailing address:
  • Phone: 618-607-1340
  • Fax: 618-622-9724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004575
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: