Provider Demographics
NPI:1669422630
Name:BRACK, TODD R (DO)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:R
Last Name:BRACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3043
Mailing Address - Country:US
Mailing Address - Phone:312-770-2181
Mailing Address - Fax:312-770-3159
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3043
Practice Address - Country:US
Practice Address - Phone:312-770-2181
Practice Address - Fax:312-770-3159
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360932032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093203Medicaid
ILK27319Medicare PIN
ILF72998Medicare UPIN