Provider Demographics
NPI:1285876979
Name:GOMOLL, BRIAN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:GOMOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-2002
Mailing Address - Fax:708-202-2024
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-2002
Practice Address - Fax:708-202-2024
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361300842084B0040X, 2084P0301X
IL036.1300842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2084P0301XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBrain Injury Medicine