Provider Demographics
NPI:1982603924
Name:BLACKER, BRUCE A (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:BLACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N SHERIDAN RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6157
Mailing Address - Country:US
Mailing Address - Phone:773-472-5803
Mailing Address - Fax:
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6157
Practice Address - Country:US
Practice Address - Phone:773-472-5803
Practice Address - Fax:773-472-7902
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072584Medicaid
1982603924Medicare PIN
IL202712Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL036072584Medicaid