Provider Demographics
NPI:1285613463
Name:BRATTAIN, THOMAS KEVIN (DPM)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:KEVIN
Last Name:BRATTAIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 W WILLOW KNOLLS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8148
Mailing Address - Country:US
Mailing Address - Phone:309-691-5800
Mailing Address - Fax:309-691-1336
Practice Address - Street 1:3322 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8148
Practice Address - Country:US
Practice Address - Phone:309-691-5800
Practice Address - Fax:309-691-1336
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003267213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007215174OtherBLUE CROSS BLUE SHIELD
IL016003267Medicaid
IL928270OtherMEDICARE PROVIDER NUMBER
IL480009789OtherMEDICARE RAILROAD
ILL11387Medicare PIN
IL480009789OtherMEDICARE RAILROAD
ILT37674Medicare UPIN