=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659599538
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRETT MICHAEL DEMPSEY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 01/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 S PARK AVE FL 3
-----------------------------------------------------
City | HERRIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62948-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-942-2002
-----------------------------------------------------
Fax | 618-351-6497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3988
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62902-3988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-457-5200
-----------------------------------------------------
Fax | 618-529-0586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 50805
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036130706
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------