Provider Demographics
NPI:1710474887
Name:FILLINGER, BROOKLYN RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:BROOKLYN
Middle Name:RAE
Last Name:FILLINGER
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 1:17600 TRAILWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:OH
Mailing Address - Zip Code:44099-9609
Mailing Address - Country:US
Mailing Address - Phone:843-957-8852
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-6462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.073802207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-3971298Medicaid