1457355315 NPI number — DR. ROBERT JUDSON BREWER M.D.

Table of content: DR. ROBERT JUDSON BREWER M.D. (NPI 1457355315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457355315 NPI number — DR. ROBERT JUDSON BREWER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREWER
Provider First Name:
ROBERT
Provider Middle Name:
JUDSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1457355315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-549-5361
Provider Business Mailing Address Fax Number:
618-549-5128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 S PARK AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-942-2002
Provider Business Practice Location Address Fax Number:
618-351-6497
Provider Enumeration Date:
06/09/2005

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: 208600000X , with the licence number:  23499 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 036117928 , 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: 7210895 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036117928 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3932056 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 654532 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 133018 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 319226 . This is a "GHP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 64234990 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com