Provider Demographics
NPI:1114923497
Name:PHILLIPS, BRYAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:PHILLIPS
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 1:718 S WEBER ROAD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490
Mailing Address - Country:US
Mailing Address - Phone:630-378-4799
Mailing Address - Fax:630-378-4783
Practice Address - Street 1:718 S WEBER ROAD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490
Practice Address - Country:US
Practice Address - Phone:630-378-4799
Practice Address - Fax:630-378-4783
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098037207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180039547OtherRAILROAD MEDICARE
IL0031600193OtherBLUE SHIELD
IL036098037Medicaid
ILK46495OtherMEDICARE PROVIDER NUMBER
IL3970320001OtherDMERC
ILG89436Medicare UPIN
IL211428Medicare PIN