Provider Demographics
NPI:1891757720
Name:IRWIN, BRUCE WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WILLIAM
Last Name:IRWIN
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 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-549-1609
Mailing Address - Fax:847-549-1646
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE 206
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-549-1609
Practice Address - Fax:847-549-1646
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086240207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360862401Medicaid
IL04920125OtherBC/BS OF IL
ILL37984Medicare PIN