Basic Information
| Provider Information | |||||||||
| NPI: | 1093975500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALCOTT | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CENTRAL ST STE 880 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701440 | ||||||||
| FaxNumber: | 8475701442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 CENTRAL ST STE 880 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701440 | ||||||||
| FaxNumber: | 8475701442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 036.149400 | IL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036149400 | 01 | IL | STATE LICENSE | OTHER |