MEDICARE: BRANDI FIELDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1164072831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI FIELDS

Provider Business Mailing Address
First Line	:	1600 LORETTA AVE
Second Line	:
City	:	CAHOKIA
State	:	IL
Zip	:	62206-2305
Country	:	US
Telephone Number	:	618-578-3627
Fax Number	:

Provider Business Practice Location Address
First Line	:	6400 W MAIN ST STE 3K
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3806
Country	:	US
Telephone Number	:	618-578-3627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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Directions to “ BRANDI FIELDS ” Practice Location

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