Provider Demographics
NPI:1871655589
Name:BRASOVAN, SRBISLAV N (MD)
Entity Type:Individual
Prefix:DR
First Name:SRBISLAV
Middle Name:N
Last Name:BRASOVAN
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 1:7903 E 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8599
Mailing Address - Country:US
Mailing Address - Phone:219-738-2742
Mailing Address - Fax:219-942-0740
Practice Address - Street 1:111 W 10TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5990
Practice Address - Country:US
Practice Address - Phone:219-738-2742
Practice Address - Fax:219-942-0740
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022104A207VG0400X
IL036103826207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000229829OtherBLUECROSSBLUESHIELD
IN000000229829OtherBLUECROSSBLUESHIELD
INB29060Medicare UPIN
IN233300Medicare PIN