1750487526 NPI number — DR. PATRICIA A BROSSARD D.C.

Table of content: DR. PATRICIA A BROSSARD D.C. (NPI 1750487526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750487526 NPI number — DR. PATRICIA A BROSSARD D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROSSARD
Provider First Name:
PATRICIA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1750487526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3907 FARMINGTON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60051-5175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 S WYNSTONE PARK DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
N BARRINGTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60010-6979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-540-6060
Provider Business Practice Location Address Fax Number:
847-277-8012
Provider Enumeration Date:
09/16/2006

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: 111N00000X , with the licence number:  038-005836 , 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: 0024949396 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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