Provider Demographics
NPI:1205071149
Name:BRADLEY W. BUCKROP DPM
Entity type:Organization
Organization Name:BRADLEY W. BUCKROP DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BUCKROP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-788-3668
Mailing Address - Street 1:3727 46TH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7078
Mailing Address - Country:US
Mailing Address - Phone:309-788-3668
Mailing Address - Fax:309-786-5168
Practice Address - Street 1:3727 46TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7078
Practice Address - Country:US
Practice Address - Phone:309-788-3668
Practice Address - Fax:309-786-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00545213ES0131X
IL01600458213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8182069OtherBLUE CROSS BLUE SHILD
IL016004658Medicaid
IL016004658Medicaid
IL016004658Medicaid
U33388Medicare UPIN
IL0741910001Medicare NSC
BB3472711OtherDEA