1760617062 NPI number — MRS. MELISSA R BROUSIL BA, MAOL

Table of content: MRS. MELISSA R BROUSIL BA, MAOL (NPI 1760617062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760617062 NPI number — MRS. MELISSA R BROUSIL BA, MAOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSIL
Provider First Name:
MELISSA
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BA, MAOL
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:
1760617062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17390 OTTAWA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-3235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-212-0300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2445 BIRDSALL ST
Provider Second Line Business Practice Location Address:
APT# 5
Provider Business Practice Location Address City Name:
BLUE ISLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60406-1748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-212-0300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2009

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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