Provider Demographics
NPI:1003839507
Name:BIRLY, JOHN W (DC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:BIRLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 MULFORD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6657
Mailing Address - Country:US
Mailing Address - Phone:815-398-7264
Mailing Address - Fax:815-229-7264
Practice Address - Street 1:6116 MULFORD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6657
Practice Address - Country:US
Practice Address - Phone:815-398-7264
Practice Address - Fax:815-229-7264
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37182Medicare UPIN
IL203131Medicare ID - Type Unspecified