Provider Demographics
NPI:1306907779
Name:BROTHERSON, KURT JEFFREY (MD)
Entity type:Individual
Prefix:MR
First Name:KURT
Middle Name:JEFFREY
Last Name:BROTHERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 N WESTMORELAND RD
Mailing Address - Street 2:BLDG B
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1679
Mailing Address - Country:US
Mailing Address - Phone:847-482-0136
Mailing Address - Fax:847-482-0302
Practice Address - Street 1:700 N WESTMORELAND RD
Practice Address - Street 2:BLDG B
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1679
Practice Address - Country:US
Practice Address - Phone:847-482-0136
Practice Address - Fax:847-482-0302
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C421170Medicaid
A37748Medicare UPIN
CA00C421170Medicaid
CAC42117Medicare PIN