Provider Demographics
NPI:1114078201
Name:SIWIEC, BRIAN CRAIG (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CRAIG
Last Name:SIWIEC
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 1:124 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-3752
Mailing Address - Country:US
Mailing Address - Phone:732-232-0935
Mailing Address - Fax:732-928-1286
Practice Address - Street 1:19 N COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-1255
Practice Address - Country:US
Practice Address - Phone:732-232-0935
Practice Address - Fax:732-928-1286
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00596600111N00000X
NYX010834111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ067455Medicare PIN
NJU94029Medicare UPIN