1013960244 NPI number — DR. BEVERLEE A BRISBIN MD

Table of content: DR. BEVERLEE A BRISBIN MD (NPI 1013960244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013960244 NPI number — DR. BEVERLEE A BRISBIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISBIN
Provider First Name:
BEVERLEE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013960244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10330 S ROBERTS RD
Provider Second Line Business Mailing Address:
MIDAMERICA ORTHOPAEDICS, S.C.
Provider Business Mailing Address City Name:
PALOS HILLS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60465-1971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-237-7200
Provider Business Mailing Address Fax Number:
708-237-7201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10330 S ROBERTS RD
Provider Second Line Business Practice Location Address:
MIDAMERICA ORTHOPAEDICS, S.C.
Provider Business Practice Location Address City Name:
PALOS HILLS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60465-1971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-237-7200
Provider Business Practice Location Address Fax Number:
708-237-7201
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X , with the licence number:  036-103749 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 250013909 . This is a "RAILROAD MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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