Provider Demographics
NPI:1205862570
Name:CORSO, ROMAN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:MICHAEL
Last Name:CORSO
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 1:915 W SPRESSER ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1831
Mailing Address - Country:US
Mailing Address - Phone:217-824-5010
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:217-824-5010
Practice Address - Fax:217-824-5511
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
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
IL206046Medicare ID - Type Unspecified
ILU94760Medicare UPIN