Provider Demographics
NPI:1912923269
Name:BROWN, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3183 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0031
Mailing Address - Country:US
Mailing Address - Phone:708-492-0502
Mailing Address - Fax:708-492-0565
Practice Address - Street 1:6440 GRAND AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5257
Practice Address - Country:US
Practice Address - Phone:847-782-8349
Practice Address - Fax:847-782-8546
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090508208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214706OtherMEDICARE
ILDE5300OtherMEDICARE
IL036090508Medicaid
IL1518027812OtherNPI
ILR00709OtherMEDICARE
IL01635877OtherBCBS
04921836OtherBLUE CROSS BLUE SHIELD
IL212210OtherMEDICARE
IL212210017Medicare PIN
ILR00709OtherMEDICARE
IL01635877OtherBCBS