Provider Demographics
NPI:1184618258
Name:BREWER, BENJAMIN EMERT (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:EMERT
Last Name:BREWER
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 1:122 E WABASH AVE
Mailing Address - Street 2:P O BOX 58
Mailing Address - City:FORREST
Mailing Address - State:IL
Mailing Address - Zip Code:61741-0058
Mailing Address - Country:US
Mailing Address - Phone:815-657-8707
Mailing Address - Fax:815-657-8717
Practice Address - Street 1:122 E WABASH AVE
Practice Address - Street 2:
Practice Address - City:FORREST
Practice Address - State:IL
Practice Address - Zip Code:61741-0058
Practice Address - Country:US
Practice Address - Phone:815-657-8707
Practice Address - Fax:815-657-8717
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
IL825130012Medicare PIN
IL$$$$$$$$$Medicaid
ILK08556Medicare ID - Type Unspecified