1760597140 NPI number — DR. JOEL G. BRASCH MD

Table of content: DR. JOEL G. BRASCH MD (NPI 1760597140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760597140 NPI number — DR. JOEL G. BRASCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRASCH
Provider First Name:
JOEL
Provider Middle Name:
G.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1760597140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5225 OLD ORCHARD RD
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60077-4405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-966-8815
Provider Business Mailing Address Fax Number:
847-966-8305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10811 W 143RD ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ORLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60467-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-403-4210
Provider Business Practice Location Address Fax Number:
708-403-5272
Provider Enumeration Date:
08/19/2006

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: 207VE0102X , with the licence number:  01041509A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VE0102X , 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: 1620606 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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