Provider Demographics
NPI:1487643813
Name:WILLIAMS, BRENT S (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:S
Last Name:WILLIAMS
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 1:1805 HENNEPIN AVE N
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-1416
Mailing Address - Country:US
Mailing Address - Phone:320-864-3121
Mailing Address - Fax:320-864-7887
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:GLENCOE REGIONAL HEALTH SERVICES
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:320-864-7887
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
089003941Medicare ID - Type Unspecified
D64088Medicare UPIN