Provider Demographics
NPI:1457355315
Name:BREWER, ROBERT JUDSON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JUDSON
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:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-549-5128
Practice Address - Street 1:220 S PARK AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3612
Practice Address - Country:US
Practice Address - Phone:618-942-2002
Practice Address - Fax:618-351-6497
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23499208600000X
IL036117928208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7210895OtherAETNA
IL036117928Medicaid
IL3932056OtherBCBS
IL654532OtherHEALTHLINK
IL133018OtherHEALTH ALLIANCE
IL319226OtherGHP
KY64234990Medicaid
IL3932056OtherBCBS
IL133018OtherHEALTH ALLIANCE
IL7210895OtherAETNA