Provider Demographics
NPI:1710242854
Name:SWANSON, BROCK ANDREW (DPM)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:ANDREW
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-224-6423
Mailing Address - Fax:
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-224-6423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005681213ES0103X
PASC006387213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery