Provider Demographics
NPI:1558460022
Name:SASSO, BRIAN C (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:SASSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 N CONVENT ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-937-5200
Mailing Address - Fax:815-937-2063
Practice Address - Street 1:1615 N CONVENT ST
Practice Address - Street 2:STE 1
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-937-5200
Practice Address - Fax:815-937-2063
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107298207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
ILI30155Medicare UPIN
ILK19097Medicare ID - Type UnspecifiedIL MEDICARE