MEDICARE: CRYSTAL BROZOVICH PA

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1740957455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL BROZOVICH PA

Provider Business Mailing Address
First Line	:	725 SCHOOL ST STE A
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-1207
Country	:	US
Telephone Number	:	815-705-1405
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 N DIVISION ST STE 201
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-1183
Country	:	US
Telephone Number	:	815-513-5625
Fax Number	:

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

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	03/15/2024

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Directions to “ CRYSTAL BROZOVICH PA” Practice Location

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