Provider Demographics
NPI:1164471264
Name:ROSSER, JOHN RUCKS JR (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUCKS
Last Name:ROSSER
Suffix:JR
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 1:1276 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3304
Mailing Address - Country:US
Mailing Address - Phone:847-741-6400
Mailing Address - Fax:847-741-6926
Practice Address - Street 1:1276 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-3304
Practice Address - Country:US
Practice Address - Phone:847-741-6400
Practice Address - Fax:847-741-6926
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003342111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4515124OtherBCBS
P15933Medicare UPIN
IL681740Medicare ID - Type Unspecified