Healthcare Provider Details

I. General information

NPI: 1982603924
Provider Name (Legal Business Name): BRUCE A BLACKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 N SHERIDAN RD SUITE 400
CHICAGO IL
60657-6157
US

IV. Provider business mailing address

2800 N SHERIDAN RD SUITE 400
CHICAGO IL
60657-6157
US

V. Phone/Fax

Practice location:
  • Phone: 773-472-5803
  • Fax: 773-472-7902
Mailing address:
  • Phone: 773-472-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036072584
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: