NPIMap

Organization Active NPI

Waukegan Medical and Rehabilitation

  • Rehabilitation Chiropractor
  • Waukegan, IL
National Provider Identifier
1396892352
Registry record updated Jan 19, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rehabilitation ChiropractorTaxonomy code 111NR0400X
License
038007449 Issued in IL
Legal business name
WAUKEGAN MEDICAL AND REHABILITATION
Practice address
1720 Grand Ave
Waukegan, IL 60085-3502
Phone
(847) 625-0202
Fax
(847) 625-0101
NPI assigned
Jan 4, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 19, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ivan Bracic, D.C.
Title
President-Owner
Phone
(847) 625-0202

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rehabilitation ChiropractorGroup: 193200000X MULTI-SPECIALTY GROUP 111NR0400X 038007449 IL Primary
Physical Therapy AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 225200000X 160-004131 IL

Addresses

Primary practice location

1720 Grand Ave
Waukegan, IL 60085-3502

Mailing address

1720 Grand Ave
Waukegan, IL 60085-3502
Phone (847) 625-0202

Other identifiers 1

IdentifierTypeStateIssuer
04932043OtherILBLUE CROSS BLUE SHIELD

Other names 1

  • Waukegan Medical Center Former legal business name

National Provider Directory

National Provider Directory
Tax ID family
Waukegan Medical and Rehabilitation2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167868800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1453161600000",
    "number": "1396892352",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1720 GRAND AVE",
            "city": "WAUKEGAN",
            "state": "IL",
            "postal_code": "600853502",
            "telephone_number": "847-625-0202",
            "fax_number": "847-625-0101"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1720 GRAND AVE",
            "city": "WAUKEGAN",
            "state": "IL",
            "postal_code": "600853502",
            "telephone_number": "847-625-0202",
            "fax_number": "847-625-0101"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAUKEGAN MEDICAL AND REHABILITATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-04",
        "last_updated": "2016-01-19",
        "status": "A",
        "authorized_official_last_name": "BRACIC",
        "authorized_official_first_name": "IVAN",
        "authorized_official_title_or_position": "PRESIDENT-OWNER",
        "authorized_official_telephone_number": "847-625-0202",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.C."
    },
    "taxonomies": [
        {
            "code": "111NR0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor, Rehabilitation",
            "state": "IL",
            "license": "038007449",
            "primary": true
        },
        {
            "code": "225200000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapy Assistant",
            "state": "IL",
            "license": "160-004131",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "04932043",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Waukegan Medical Center",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Waukegan, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.