Provider Demographics
NPI:1134466485
Name:BROOKS, COREY AUSTIN (PA)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:AUSTIN
Last Name:BROOKS
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:618-607-1340
Mailing Address - Fax:618-622-9724
Practice Address - Street 1:1418 CROSS ST
Practice Address - Street 2:DIV IM MEDICAL ONCOLOGY, STE 180
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2914
Practice Address - Country:US
Practice Address - Phone:618-607-1340
Practice Address - Fax:618-622-9724
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085004575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220143984Medicaid