Provider Demographics
NPI:1578953972
Name:MEDICI, BROOK ERNESTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:ERNESTINE
Last Name:MEDICI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1411
Mailing Address - Country:US
Mailing Address - Phone:847-876-9300
Mailing Address - Fax:
Practice Address - Street 1:1550 N NORTHWEST HWY
Practice Address - Street 2:SUITE 211
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1411
Practice Address - Country:US
Practice Address - Phone:847-876-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant