Provider Demographics
NPI:1871637454
Name:BRUCE A. BROWN, M.D., S.C.
Entity Type:Organization
Organization Name:BRUCE A. BROWN, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-782-8349
Mailing Address - Street 1:PO BOX 222
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-0222
Mailing Address - Country:US
Mailing Address - Phone:847-405-0654
Mailing Address - Fax:847-405-0658
Practice Address - Street 1:6440 GRAND AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5257
Practice Address - Country:US
Practice Address - Phone:847-782-8349
Practice Address - Fax:847-782-8546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
04921836OtherBLUE CROSS BLUR SHIELD
K05553Medicare UPIN
208703Medicare PIN