Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 036.149400 | IL |
NPI | 1093975500 |
---|---|
Provider Name | Brian P Walcott |
First Address | Evanston, IL 60201-1780 |
Second Address | Evanston, IL 60201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2008 |
Last Update Date | 11/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036149400 | STATE LICENSE (01) | IL |