Provider Demographics
NPI:1063829372
Name:FILL, BRYAN (APN)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:FILL
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NORTH WINFIELD ROAD
Mailing Address - Street 2:CDH-FLR 4-NORTH TOWER
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-4267
Mailing Address - Fax:
Practice Address - Street 1:25 NORTH WINFIELD ROAD
Practice Address - Street 2:CDH-FLR 4-NORTH TOWER
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041375998163W00000X
IL209011835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN GROUP
ILF400228277OtherMEDICARE PTAN INDIVIDUAL