Provider Demographics
NPI:1508887860
Name:STOECKER, BRAD A (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:A
Last Name:STOECKER
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 1:401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IL
Mailing Address - Zip Code:61561-7516
Mailing Address - Country:US
Mailing Address - Phone:309-923-2661
Mailing Address - Fax:309-923-7628
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7516
Practice Address - Country:US
Practice Address - Phone:309-923-2661
Practice Address - Fax:309-923-7628
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116395Medicaid
ILCA2182OtherRR MEDICARE GROUP PTAN (PONTIAC)
IL809840OtherMEDICARE GROUP #
P00406153OtherRR MEDICARE IND. #
833230OtherGROUP # FOR PONTIAC
CA4079OtherRR MEDICARE GROUP #
ILP00601872OtherRR MEDICARE IND PTAN (PONTIAC)
K38961Medicare PIN
ILCA2182OtherRR MEDICARE GROUP PTAN (PONTIAC)