Provider Demographics
NPI:1083619449
Name:NOVAK, RICHARD M (DC, CCST)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:NOVAK
Suffix:
Gender:M
Credentials:DC, CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4A OAK DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5809
Mailing Address - Country:US
Mailing Address - Phone:618-288-8075
Mailing Address - Fax:618-288-8095
Practice Address - Street 1:4A OAK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5809
Practice Address - Country:US
Practice Address - Phone:618-288-8075
Practice Address - Fax:618-288-8095
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
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
IL2468996OtherAETNA
IL410486OtherHEALTHLINK
IL44-90308OtherUNITED HEALTH CARE
IL63313OtherCMR
IL0006026476OtherBLUE CROSS BLUE SHIELD
IL410486OtherHEALTHLINK