Provider Demographics
NPI:1255322459
Name:BROOKS, GREG A (CRNA)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:A
Last Name:BROOKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N KINGSBURY ST UNIT 3201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8777
Mailing Address - Country:US
Mailing Address - Phone:574-229-5636
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-484-4099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162626A367500000X
TXAP114460367500000X
IL209009504367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200508510Medicaid
IN200508510Medicaid