Healthcare Provider Details

I. General information

NPI: 1811918964
Provider Name (Legal Business Name): CAROLYN S. BRECKLIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

4651 N KNOX AVE
CHICAGO IL
60630-4029
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4600
  • Fax:
Mailing address:
  • Phone: 312-864-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: