Provider Demographics
NPI:1144208349
Name:CYCHOLL, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CYCHOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 STACEY BURK DR
Mailing Address - Street 2:CLAY COUNTY HOSPITAL MEDICAL CLINIC
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-3241
Mailing Address - Country:US
Mailing Address - Phone:618-662-2131
Mailing Address - Fax:618-662-3077
Practice Address - Street 1:929 STACEY BURK DR
Practice Address - Street 2:CLAY COUNTY HOSPITAL MEDICAL CLINIC
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-3241
Practice Address - Country:US
Practice Address - Phone:618-662-2131
Practice Address - Fax:618-662-3077
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
482023OtherHEALTHLINK
086757OtherHEALTH ALLIANCE
IL036107332Medicaid
H88359Medicare UPIN
086757OtherHEALTH ALLIANCE