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General NPI Number Information
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NPI Number | 1629181284
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Entity Type | Organization
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Legal Business Name | DEERBROOK MEDICAL ASSOCIATES
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 04/26/2024
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Provider Practice Location Address
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Address Line | 1870 W WINCHESTER RD STE 112
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-5365
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Country | US
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Telephone | 847-224-0165
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Fax | 847-247-2840
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Provider Business Mailing Address
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Address Line | 1870 W WINCHESTER RD STE 112
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-5365
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Country | US
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Telephone | 847-224-0165
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Fax | 847-247-2840
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Authorized Official
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Title or Position | OWNER
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Name | DR. IRA FENTON
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Credential | DO
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Telephone | 847-367-7340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 36058893
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085001035
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 36110464
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License Number State | IL
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