Mary L Brandenburg, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

085-001021 Issued in IL

Practice address

1301 E Walnut St
Carbondale, IL 62901-5004

Phone

(618) 457-3371

Fax

(618) 457-8931

NPI assigned

Aug 20, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 4

Other names 1

• Mary L Brecht Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Shawnee Health Service and Development Corp

  • Federally Qualified Health Center (FQHC)
  • Carbondale, IL
  • NPI 1073745345
  NPD (past)
• Shawnee Health Service and Development Corp

  • Case Management Agency
  • Carterville, IL
  • NPI 1639651706
  NPD (past)
• Shawnee Health Service and Development Corp

  • Community/Retail Pharmacy
  • Carbondale, IL
  • NPI 1760253447
  NPD (past)
• Shawnee Health Service and Development Corp

  • Federally Qualified Health Center (FQHC)
  • Carterville, IL
  • NPI 1811928732
  NPD (past)
• Shawnee Health Service and Development Corp

  • Federally Qualified Health Center (FQHC)
  • Marion, IL
  • NPI 1881624161
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156032000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1347494400000",
    "number": "1649385873",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 577",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "629180577",
            "telephone_number": "618-985-8221"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 E WALNUT ST",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629015004",
            "telephone_number": "618-457-3371",
            "fax_number": "618-457-8931"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRANDENBURG",
        "first_name": "MARY",
        "middle_name": "L",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-20",
        "last_updated": "2012-09-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085-001021",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "370966854015",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RR",
            "identifier": "CF3444",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH ALLIANCE",
            "identifier": "105008",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE NUMBER",
            "identifier": "085001021",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MARY",
            "last_name": "BRECHT",
            "middle_name": "L",
            "credential": "PA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Amanda J Bowers, FNP
• Annamaria Boyce, CRNA
• Brad McMillin, Inc
• Austin Bradley, FNP-C
• Datrese Monique Bradley, LCPC
• Debra Lynn Braunling McMorrow, PHD
• Brian G. McElheny, M.D. LTD
• Brigham Anesthesia South LLC
• Jayda Brink
• Kezia Briones, PA-C

• Physician Assistant in Carbondale, IL
• Providers in Carbondale, IL by specialty
• Physician Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 13, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.