Provider Demographics
NPI:1477835544
Name:BREWER, AUDREY GENNIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:GENNIEL
Last Name:BREWER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2460
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics