Provider Demographics
NPI:1720046774
Name:MOLINE, BRYAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:G
Last Name:MOLINE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1730 PARK ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2688
Mailing Address - Country:US
Mailing Address - Phone:630-718-0200
Mailing Address - Fax:630-718-0900
Practice Address - Street 1:610 S MAPLE AVE
Practice Address - Street 2:SUITE 2100
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1091
Practice Address - Country:US
Practice Address - Phone:708-660-2240
Practice Address - Fax:708-660-2243
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-08-22
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Provider Licenses
StateLicense IDTaxonomies
IL036074841207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074841Medicaid
ILE19102Medicare UPIN