Provider Demographics
NPI:1679645287
Name:RAE, BRONWYN R (MD)
Entity Type:Individual
Prefix:
First Name:BRONWYN
Middle Name:R
Last Name:RAE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-880-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085516207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology