Provider Demographics
NPI:1861614380
Name:TIERNAN, BRECK MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:BRECK
Middle Name:MICHAEL
Last Name:TIERNAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:BROECKERT
Other - Middle Name:MICHAEL
Other - Last Name:TIERNAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:350 HOUBOLT RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8305
Mailing Address - Country:US
Mailing Address - Phone:815-553-0990
Mailing Address - Fax:815-553-0991
Practice Address - Street 1:350 HOUBOLT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8305
Practice Address - Country:US
Practice Address - Phone:815-553-0990
Practice Address - Fax:815-553-0991
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16005321213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery