Individual
MARY L BRANDENBURG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1301 E WALNUT ST, CARBONDALE, IL 62901-5004
(618) 457-3371
(618) 457-8931
Mailing address
PO BOX 577, CARTERVILLE, IL 62918-0577
(618) 985-8221
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085-001021
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085001021
STATE LICENSE NUMBER
IL
01
—
105008
HEALTH ALLIANCE
IL
05
—
370966854015
—
IL
01
—
CF3444
MEDICARE RR
IL
Enumeration date
08/20/2006
Last updated
09/13/2012
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