MEDICARE: ERIC BRUECKNER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	15768-24	WI

General Provider Information

NPI Number	:	1205571445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC BRUECKNER DPT

Provider Business Mailing Address
First Line	:	16980 HIDDEN POND CT
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-4429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1631 W LINCOLN AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-2637
Country	:	US
Telephone Number	:	414-643-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2022
Last Update Date	:	05/02/2022

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