Provider Demographics
NPI:1154387850
Name:PRYWITCH, BRETT
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:PRYWITCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 DEER TRACKS TRL
Mailing Address - Street 2:STE 130
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 STATE ST
Practice Address - Street 2:CHESTER MEMORIAL HOSPITAL
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1116
Practice Address - Country:US
Practice Address - Phone:618-826-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILMD4666002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
290473OtherHEALTHLINK
IL0360823072Medicaid
IL3682307OtherBLUE CROSS BLUE SHIELD
ILL54171Medicare ID - Type Unspecified
IL3682307OtherBLUE CROSS BLUE SHIELD