Provider Demographics
NPI:1609022003
Name:WEATHERFORD, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WEATHERFORD
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 1:900 RAND RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:
Practice Address - Street 1:2401 RAVINE WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7645
Practice Address - Country:US
Practice Address - Phone:847-998-5680
Practice Address - Fax:847-998-6365
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-133355207X00000X
MI4301106004207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD14869OtherGROUP PTAN