Provider Demographics
NPI:1073604534
Name:OLOFSSON, BRIAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:OLOFSSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N WALL
Mailing Address - Street 2:SUITE 510
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-932-5725
Mailing Address - Fax:815-932-5872
Practice Address - Street 1:400 N WALL
Practice Address - Street 2:SUITE 510
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-932-5725
Practice Address - Fax:815-932-5872
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067325Medicaid
IL036067325Medicaid
IL219640Medicare ID - Type Unspecified