Provider Demographics
NPI:1629040191
Name:ENGEBRECHT, BRIAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:P
Last Name:ENGEBRECHT
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 1:608 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6145
Mailing Address - Country:US
Mailing Address - Phone:309-277-3500
Mailing Address - Fax:309-277-3050
Practice Address - Street 1:608 35TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6145
Practice Address - Country:US
Practice Address - Phone:309-277-3500
Practice Address - Fax:309-277-3050
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090807208800000X
IA32089208800000X
IL036-090807208800000X
IAMD-32089208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090807Medicaid
IL036090807Medicaid
IL392140Medicare PIN
ILF400239249Medicare PIN