Provider Demographics
NPI:1639559719
Name:NATHAN, BRENT M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:M
Last Name:NATHAN
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 1:2101 WAUKEGAN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1836
Mailing Address - Country:US
Mailing Address - Phone:847-317-1717
Mailing Address - Fax:847-317-9305
Practice Address - Street 1:2101 WAUKEGAN RD STE 104
Practice Address - Street 2:
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1836
Practice Address - Country:US
Practice Address - Phone:847-317-1717
Practice Address - Fax:847-317-9305
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125067282207R00000X
IL036144667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine