Provider Demographics
NPI:1477555308
Name:FONNER, BRENT T (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:T
Last Name:FONNER
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 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:630-874-2642
Practice Address - Street 1:PROVENA MERCY MEDICAL CENTER / PATHOLOGY DEPARTMENT
Practice Address - Street 2:1325 NORTH HIGHLAND AVENUE
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506
Practice Address - Country:US
Practice Address - Phone:630-859-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360883832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK05079Medicare PIN
ILG43843Medicare UPIN
ILL59307Medicare PIN