1386070480 NPI number — MR. THEODORE CRAIG BROCK APN-BC

Table of content: MR. THEODORE CRAIG BROCK APN-BC (NPI 1386070480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386070480 NPI number — MR. THEODORE CRAIG BROCK APN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
THEODORE
Provider Middle Name:
CRAIG
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APN-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386070480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 RANDALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENEVA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60134-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-232-0610
Provider Business Mailing Address Fax Number:
630-232-0675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 RANDALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-232-0610
Provider Business Practice Location Address Fax Number:
630-232-0675
Provider Enumeration Date:
09/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  209010570 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 209010570 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 041303225 . This is a "MEDICAID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA4748 . This is a "MEDICARE RAILROAD (GROUP)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P01349683 . This is a "MEDICARE RAILROAD (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206147 . This is a "MEDICARE PTAN (GROUP)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: F400112507 . This is a "MEDICARE PTAN (INDIVIDUAL)" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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