Provider Demographics
NPI:1932378221
Name:BRIAN BUCKROP
Entity type:Organization
Organization Name:BRIAN BUCKROP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-797-6565
Mailing Address - Street 1:2102 47TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3664
Mailing Address - Country:US
Mailing Address - Phone:309-797-6565
Mailing Address - Fax:309-797-8586
Practice Address - Street 1:2102 47TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3664
Practice Address - Country:US
Practice Address - Phone:309-797-6565
Practice Address - Fax:309-797-8586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060101122OtherBLUE CROSS BLUE SHIELD
IL020217OtherHEALTH ALLIANCE
IL0060101122OtherBLUE CROSS BLUE SHIELD
IL635630Medicare PIN
IL020217OtherHEALTH ALLIANCE