Provider Demographics
NPI:1588643902
Name:ALBERTINI, BRAD C (PA-C)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:C
Last Name:ALBERTINI
Suffix:
Gender:M
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:PO BOX 19670
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9670
Mailing Address - Country:US
Mailing Address - Phone:217-757-8100
Mailing Address - Fax:217-747-1351
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-757-8100
Practice Address - Fax:217-747-1351
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85001668363AS0400X
IL085-001668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP51854Medicare UPIN
IL208343003Medicare PIN