Provider Demographics
NPI:1568476117
Name:ANSEEUW, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:ANSEEUW
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 1:616 35TH AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6158
Mailing Address - Country:US
Mailing Address - Phone:309-784-4729
Mailing Address - Fax:309-764-7144
Practice Address - Street 1:616 35TH AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6158
Practice Address - Country:US
Practice Address - Phone:309-704-4729
Practice Address - Fax:309-764-7144
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361027182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA94420OtherWELLMARK
IL36102716 2Medicaid
IL08126230OtherBCBS
ILK13509Medicare PIN
IA94420OtherWELLMARK