Provider Demographics
NPI:1588713374
Name:CORWIN, BRUCE C (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:CORWIN
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 1:15728 S ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2693
Mailing Address - Country:US
Mailing Address - Phone:815-436-8831
Mailing Address - Fax:815-436-6863
Practice Address - Street 1:15728 S ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2693
Practice Address - Country:US
Practice Address - Phone:815-436-8831
Practice Address - Fax:815-436-6863
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
399980OtherMEDICARE GROUP PTAN
IL036068055Medicaid
399980OtherMEDICARE GROUP PTAN
399980OtherMEDICARE GROUP PTAN
IL080038627OtherRAILROAD MEDICARE PTAN