Provider Demographics
NPI:1205867538
Name:PARKSIDE CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:PARKSIDE CHIROPRACTIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KIRCHBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-623-2610
Mailing Address - Street 1:1235 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1612
Mailing Address - Country:US
Mailing Address - Phone:920-623-2610
Mailing Address - Fax:
Practice Address - Street 1:1235 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1612
Practice Address - Country:US
Practice Address - Phone:920-623-2610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70901-012111N00000X
WI70902-012111N00000X
WI3989-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU43434Medicaid
WI70902Medicare ID - Type UnspecifiedMEDICARE DEBBIE OLDENBURG
WI70901Medicare ID - Type UnspecifiedTIM KIRCHBERG MEDICARE #
WIU43434Medicare UPIN
WIU43434Medicaid