Basic Information
| Provider Information | |||||||||
| NPI: | 1992820807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREUKER | ||||||||
| FirstName: | GERARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 E NORTH ST STE C | ||||||||
| Address2: | |||||||||
| City: | BRADLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609151188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027503 | ||||||||
| FaxNumber: | 8158027514 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 E NORTH ST STE C | ||||||||
| Address2: | |||||||||
| City: | BRADLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609151188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027503 | ||||||||
| FaxNumber: | 8158027514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 70006130 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070006130 1 | 05 | IL | MEDICAID |