MEDICARE: AIMEE C. BRUECK INC.

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01634907	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1396814380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AIMEE C. BRUECK INC.

Provider Business Mailing Address
First Line	:	1908 N MOHAWK ST
Second Line	:	UNIT 22
City	:	CHICAGO
State	:	IL
Zip	:	60614-5220
Country	:	US
Telephone Number	:	773-677-3758
Fax Number	:

Provider Business Practice Location Address
First Line	:	1908 N MOHAWK ST
Second Line	:	UNIT 22
City	:	CHICAGO
State	:	IL
Zip	:	60614-5220
Country	:	US
Telephone Number	:	773-677-3758
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. AIMEE C. BRUECK
Credential	:
Telephone Number	:	773-677-3758

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	08/22/2020

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