Provider Demographics
NPI:1992820807
Name:BREUKER, GERARD (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:GERARD
Middle Name:
Last Name:BREUKER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E NORTH ST STE C
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1188
Mailing Address - Country:US
Mailing Address - Phone:815-802-7503
Mailing Address - Fax:815-802-7514
Practice Address - Street 1:535 E NORTH ST STE C
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1188
Practice Address - Country:US
Practice Address - Phone:815-802-7503
Practice Address - Fax:815-802-7514
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70006130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070006130 1Medicaid
ILK49712Medicare PIN