Provider Demographics
NPI:1811013592
Name:BLECK, PHYLLIS C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:C
Last Name:BLECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 W 562 ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:BIG ROCK
Mailing Address - State:IL
Mailing Address - Zip Code:60511-0188
Mailing Address - Country:US
Mailing Address - Phone:630-556-3335
Mailing Address - Fax:630-556-3464
Practice Address - Street 1:48 W 562 ROUTE 30
Practice Address - Street 2:
Practice Address - City:BIG ROCK
Practice Address - State:IL
Practice Address - Zip Code:60511-0188
Practice Address - Country:US
Practice Address - Phone:630-556-3335
Practice Address - Fax:630-556-3464
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
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
IL772750Medicare ID - Type Unspecified
D89962Medicare UPIN