Healthcare Provider Details

I. General information

NPI: 1376717603
Provider Name (Legal Business Name): BRIAN A MAILEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST 3RD FLOOR
SPRINGFIELD IL
62702
US

IV. Provider business mailing address

PO BOX 19653
SPRINGFIELD IL
62794-9653
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-2588
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036-138547
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036-138547
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: