Basic Information
Provider Information | |||||||||
NPI: | 1881973014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BREITMAN | ||||||||
FirstName: | IGAL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRIGHTMAN | ||||||||
OtherFirstName: | IGAL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 122 E COLLEGE AVE | ||||||||
Address2: |   | ||||||||
City: | APPLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 549115741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209963264 | ||||||||
FaxNumber: | 9208305910 | ||||||||
Practice Location | |||||||||
Address1: | 2300 N ROCKTON AVE | ||||||||
Address2: |   | ||||||||
City: | ROCKFORD | ||||||||
State: | IL | ||||||||
PostalCode: | 611033619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159712000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2011 | ||||||||
LastUpdateDate: | 09/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35-121676 | OH | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 64663 | CT | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 390200000X | 662 | TN | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208600000X | 464 | WI | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 662 | 01 | TN | TENNESSEE MEDICAL BOARD | OTHER |