Provider Demographics
NPI:1124056205
Name:STORCK, BRANDI L (PT)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:L
Last Name:STORCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13430 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-1914
Mailing Address - Country:US
Mailing Address - Phone:815-676-3950
Mailing Address - Fax:815-676-3951
Practice Address - Street 1:4714 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-8350
Practice Address - Country:US
Practice Address - Phone:815-676-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL367885100OtherUS DEPT OF LABOR
IL1619908OtherBCBS IL GROUP NUMBER
IL1623066OtherBCBS PROVIDER NUMBER
IL1619908OtherBCBS IL GROUP NUMBER
IL367885100OtherUS DEPT OF LABOR
IL200852Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ILK52313Medicare PIN
IL1623066OtherBCBS PROVIDER NUMBER
ILK52315Medicare PIN
ILK23170Medicare PIN
IL202542Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL568080Medicare PIN