Provider Demographics
NPI:1386070480
Name:BROCK, THEODORE CRAIG (APN-BC)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:CRAIG
Last Name:BROCK
Suffix:
Gender:M
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-232-0610
Mailing Address - Fax:630-232-0675
Practice Address - Street 1:304 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-232-0610
Practice Address - Fax:630-232-0675
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010570363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041303225OtherMEDICAID
ILCA4748OtherMEDICARE RAILROAD (GROUP)
ILP01349683OtherMEDICARE RAILROAD (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
ILF400112507OtherMEDICARE PTAN (INDIVIDUAL)