Provider Demographics
NPI:1982732731
Name:BRIM, AMBER D
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:D
Last Name:BRIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17860 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4729
Mailing Address - Country:US
Mailing Address - Phone:708-476-1884
Mailing Address - Fax:708-960-4513
Practice Address - Street 1:17860 BAKER AVE
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-4729
Practice Address - Country:US
Practice Address - Phone:708-476-1884
Practice Address - Fax:708-960-4513
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01535359OtherBLUE CROSS BLUE SHIELD