Provider Demographics
NPI:1023027216
Name:POLOVICH, GREGORY R
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:POLOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 MESA VERDE CT
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-9103
Mailing Address - Country:US
Mailing Address - Phone:217-824-6222
Mailing Address - Fax:217-824-5511
Practice Address - Street 1:915 W SPRESSER ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1831
Practice Address - Country:US
Practice Address - Phone:217-824-6222
Practice Address - Fax:217-824-5511
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8782001OtherBLUE CROSS BLUE SHIELD
IL667330Medicare ID - Type Unspecified
IL8782001OtherBLUE CROSS BLUE SHIELD