Provider Demographics
NPI:1023130507
Name:BRODECH MEDICAL ASSOCIATES, SC
Entity type:Organization
Organization Name:BRODECH MEDICAL ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODECH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-772-9121
Mailing Address - Street 1:809 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4637
Mailing Address - Country:US
Mailing Address - Phone:773-772-9121
Mailing Address - Fax:773-772-3939
Practice Address - Street 1:809 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4637
Practice Address - Country:US
Practice Address - Phone:773-772-9121
Practice Address - Fax:773-772-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001618699OtherBLUE CROSS BLUE SHIELD
ILC41761Medicare UPIN
IL927050Medicare ID - Type Unspecified