Basic Information
Provider Information | |||||||||
NPI: | 1447300298 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRKIC | ||||||||
FirstName: | NENAD | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 355 E ERIE ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606113167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3122381000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 355 E ERIE ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606113167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3122381000 | ||||||||
FaxNumber: | 3122388405 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2007 | ||||||||
LastUpdateDate: | 04/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036-106237 | IL | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 2081P0301X | 036-106237 | IL | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 036106237-1 | 05 | IL |   | MEDICAID | 036106237-2 | 05 | IL |   | MEDICAID |