Provider Demographics
NPI:1649248543
Name:RECKAMP, GREGORY D (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:RECKAMP
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 1:1307 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-1022
Mailing Address - Country:US
Mailing Address - Phone:815-732-3151
Mailing Address - Fax:815-732-3718
Practice Address - Street 1:1307 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061
Practice Address - Country:US
Practice Address - Phone:815-732-3151
Practice Address - Fax:815-732-3718
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL65546OtherMEDICARE PTAN
IL036098001Medicaid
ILL65546OtherMEDICARE PTAN