Provider Demographics
NPI:1134330426
Name:BLONIGEN, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:BLONIGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 SALT CREEK LN STE 105
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2979
Mailing Address - Country:US
Mailing Address - Phone:630-734-9560
Mailing Address - Fax:630-734-9565
Practice Address - Street 1:2614 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6433
Practice Address - Country:US
Practice Address - Phone:815-725-1355
Practice Address - Fax:815-730-3020
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH570097542085R0001X
IL036.1296492085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8647001Medicare PIN
IL749640015Medicare PIN