Provider Demographics
NPI:1205233384
Name:BRENT BROWN, D.O LLC
Entity type:Organization
Organization Name:BRENT BROWN, D.O LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-689-4416
Mailing Address - Street 1:1157 N. DAMEN AVE
Mailing Address - Street 2:APT 3C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6999
Mailing Address - Country:US
Mailing Address - Phone:219-689-4416
Mailing Address - Fax:
Practice Address - Street 1:1151 N. DAMEN AVE.
Practice Address - Street 2:3C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-6999
Practice Address - Country:US
Practice Address - Phone:219-689-4416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.131728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8524Medicare UPIN