Provider Demographics
NPI:1437115722
Name:BROCKMAN, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-789-2550
Mailing Address - Fax:
Practice Address - Street 1:375 N WALL ST
Practice Address - Street 2:SUITE P640
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3483
Practice Address - Country:US
Practice Address - Phone:815-932-0911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4615036OtherBCBS PROVIDER ID
IL4615036OtherBCBS PROVIDER ID
ILK04919Medicare ID - Type UnspecifiedLOCALITY 099