Basic Information
| Provider Information | |||||||||
| NPI: | 1619199627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOCKEWITZ | ||||||||
| FirstName: | BRANDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 RELIABLE PKWY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096724809 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5401 N KNOXVILLE AVE STE 112 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616145021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096932020 | ||||||||
| FaxNumber: | 3096838850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036121479 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 036121479 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036121479 | 01 | IL | LICENSE | OTHER |