1730201716 NPI number — ANDREAS CHIROPRACTIC, P.C.

Table of content: (NPI 1730201716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730201716 NPI number — ANDREAS CHIROPRACTIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREAS CHIROPRACTIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730201716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 BUCKEYE DR
Provider Second Line Business Mailing Address:
STE 130
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62294-2347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-667-1670
Provider Business Mailing Address Fax Number:
618-667-1671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 BUCKEYE DR
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62294-2347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-667-1670
Provider Business Practice Location Address Fax Number:
618-667-1671
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDREAS
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-667-1670

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  060.008479 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 477681 . This is a "HEALTHLINK ID#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: POO107103 . This is a "RAILROAD MEDICARE#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 06032046 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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