Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RC0200X | Critical Care Medicine | 036072874 | IL |
Y | 207RP1001X | Pulmonary Disease | 036072874 | IL |
NPI | 1023190063 |
---|---|
Provider Name | Mr. John D Brofman |
First Address | Berwyn, IL 60402-3471 |
Second Address | Berwyn, IL 60402-3471 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2006 |
Last Update Date | 18/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036072874 | (05) | IL |
36072874 | STATE OF ILLINOIS LICENSE (01) | IL |
E19049 | (02) | IL |
P00061472 | RAILROAD MEDICARE PIN (01) | IL |