Provider Demographics
NPI:1649462672
Name:BRIAN J ANSEEUW M.D. S.C.
Entity type:Organization
Organization Name:BRIAN J ANSEEUW M.D. S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ANSEEUW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-764-4729
Mailing Address - Street 1:616 35TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6158
Mailing Address - Country:US
Mailing Address - Phone:309-764-4729
Mailing Address - Fax:309-764-7144
Practice Address - Street 1:616 35TH AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5925
Practice Address - Country:US
Practice Address - Phone:309-764-4729
Practice Address - Fax:309-764-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618374204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102718 2Medicaid
IA94420OtherWELLMARK
IL08126230OtherBCBS
IL210689Medicare PIN
IL08126230OtherBCBS