Provider Demographics
NPI:1104978303
Name:BRETT BECKER DPM INC
Entity type:Organization
Organization Name:BRETT BECKER DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:C
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-458-1620
Mailing Address - Street 1:1491 MERCHANT DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102
Mailing Address - Country:US
Mailing Address - Phone:847-458-1620
Mailing Address - Fax:847-458-1694
Practice Address - Street 1:1491 MERCHANT DRIVE
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:847-458-1620
Practice Address - Fax:847-458-1694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003984213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532031OtherBCBS
IL016003984Medicaid
IL206720Medicare ID - Type Unspecified
IL016003984Medicaid