Provider Demographics
NPI:1255400453
Name:BREITBACH, ANTHONY L (DC)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:L
Last Name:BREITBACH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3131
Mailing Address - Country:US
Mailing Address - Phone:847-869-1772
Mailing Address - Fax:847-869-2733
Practice Address - Street 1:1117 EMERSON ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3131
Practice Address - Country:US
Practice Address - Phone:847-869-1772
Practice Address - Fax:847-869-2733
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38010236111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001634718OtherBCBS
ILK12537Medicare UPIN
ILV02401Medicare ID - Type UnspecifiedMEDICARE