Healthcare Provider Details

I. General information

NPI: 1528564960
Provider Name (Legal Business Name): BRIAN N EBO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 08/28/2024
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BELOIT HEALTH SYSTEMS INC 1969 W HART ROAD
BELOIT WI
53511-2298
US

IV. Provider business mailing address

BELOIT HEALTH SYSTEMS INC 1969 W HART ROAD
BELOIT WI
53511-2298
US

V. Phone/Fax

Practice location:
  • Phone: 608-363-5971
  • Fax: 608-363-5737
Mailing address:
  • Phone: 608-364-2293
  • Fax: 608-363-5737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number75805-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number75805-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: