Provider Demographics
NPI:1801830799
Name:MCBRIDE, DOREENA M (MD)
Entity Type:Individual
Prefix:
First Name:DOREENA
Middle Name:M
Last Name:MCBRIDE
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 1:461 BROWN BLVD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2322
Mailing Address - Country:US
Mailing Address - Phone:815-933-5700
Mailing Address - Fax:815-933-8011
Practice Address - Street 1:461 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2322
Practice Address - Country:US
Practice Address - Phone:815-933-5700
Practice Address - Fax:815-933-8011
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086437208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086437Medicaid
IL4604555OtherBCBS