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General NPI Number Information
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NPI Number | 1205233384
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Entity Type | Organization
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Legal Business Name | BRENT BROWN, D.O LLC
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Dates
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Enumeration Date | 12/04/2014
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Last Update Date | 12/04/2014
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Provider Practice Location Address
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Address Line | 1151 N. DAMEN AVE. 3C
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City | CHICAGO
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State | IL
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Zip | 60622-6999
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Country | US
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Telephone | 219-689-4416
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Fax |
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Provider Business Mailing Address
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Address Line | 1157 N. DAMEN AVE APT 3C
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City | CHICAGO
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State | IL
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Zip | 60622-6999
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Country | US
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Telephone | 219-689-4416
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. BRENT A BROWN
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Credential | D.O
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Telephone | 219-689-4416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036.131728
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License Number State | IL
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