Provider Demographics
NPI:1891499513
Name:ECKELKAMP, GRANT (DO)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:ECKELKAMP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-6002
Mailing Address - Country:US
Mailing Address - Phone:630-909-8000
Mailing Address - Fax:
Practice Address - Street 1:8701 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3548
Practice Address - Country:US
Practice Address - Phone:414-805-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.084684208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation