Provider Demographics
NPI:1629181284
Name:DEERBROOK MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:DEERBROOK MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-367-7340
Mailing Address - Street 1:565 LAKEVIEW PKWY
Mailing Address - Street 2:SUITE 116
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1857
Mailing Address - Country:US
Mailing Address - Phone:847-367-7340
Mailing Address - Fax:847-247-2840
Practice Address - Street 1:565 LAKEVIEW PKWY
Practice Address - Street 2:SUITE 116
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1857
Practice Address - Country:US
Practice Address - Phone:847-367-7340
Practice Address - Fax:847-247-2840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36110464207R00000X
IL36058893207RR0500X
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL952640Medicare ID - Type Unspecified