Provider Demographics
NPI:1730123134
Name:BRANSHAW, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:BRANSHAW
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 1:1180 W WILSON ST
Mailing Address - Street 2:STE E
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-7611
Mailing Address - Country:US
Mailing Address - Phone:630-879-5700
Mailing Address - Fax:
Practice Address - Street 1:1180 W WILSON ST
Practice Address - Street 2:STE E
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-7611
Practice Address - Country:US
Practice Address - Phone:630-879-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094251Medicaid
380970Medicare PIN
IL036094251Medicaid