Provider Demographics
NPI:1639363344
Name:BRIAN P IGOE MD SC
Entity Type:Organization
Organization Name:BRIAN P IGOE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRIMARY
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:IGOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-442-8262
Mailing Address - Street 1:347 E BURLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2149
Mailing Address - Country:US
Mailing Address - Phone:708-442-8262
Mailing Address - Fax:708-442-9119
Practice Address - Street 1:347 E BURLINGTON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2149
Practice Address - Country:US
Practice Address - Phone:708-442-8262
Practice Address - Fax:708-442-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071210261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5879001Medicare UPIN