Provider Demographics
NPI:1891768636
Name:BOSTWICK, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BOSTWICK
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 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-655-3292
Mailing Address - Fax:309-655-7732
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:PAV 4A
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-2303
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106503207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215036OtherBCBS
ILIL0104OtherJOHN DEERE
IL036106503Medicaid
IL639810Medicare ID - Type UnspecifiedMEDICARE
IL07215036OtherBCBS