Provider Demographics
NPI:1558339937
Name:BRONNER, ABRAHAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:J
Last Name:BRONNER
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 1:1912 NORTH HUDSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-587-3510
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH STREET
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60653
Practice Address - Country:US
Practice Address - Phone:708-346-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360699402085B0100X, 2085R0202X
KY402132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00928221OtherRR MEDICARE
IL036069940Medicaid
KY7100012610Medicaid
ILP00197522OtherRAILROAD MEDICARE
KYK0026101Medicare PIN
KYP00928221OtherRR MEDICARE
KYK0026102Medicare PIN
ILP00197522OtherRAILROAD MEDICARE
ILK15203Medicare ID - Type Unspecified