Basic Information
| Provider Information | |||||||||
| NPI: | 1730354382 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRECK TIERNAN PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED FOOT AND ANKLE CENTER OF JOLIET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 350 HOUBOLT RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604318305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155530990 | ||||||||
| FaxNumber: | 8155530991 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HOUBOLT RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604318305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155530990 | ||||||||
| FaxNumber: | 8155530991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TIERNAN | ||||||||
| AuthorizedOfficialFirstName: | BRECK | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8155530990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005321 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.