Provider Demographics
NPI:1356414049
Name:BRANDON, MATTHEW J (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:BRANDON
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:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:455 BRIARGATE DR.
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177
Practice Address - Country:US
Practice Address - Phone:847-622-0506
Practice Address - Fax:847-622-0507
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105926207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105926 3Medicaid
IL4532366OtherBCBS
IL036105926 3Medicaid
ILK31977Medicare PIN