Provider Demographics
NPI:1275539611
Name:FAST, ROBERT J (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:FAST
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 1:5206 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4731
Mailing Address - Country:US
Mailing Address - Phone:628-234-5200
Mailing Address - Fax:618-234-4400
Practice Address - Street 1:5206 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-4731
Practice Address - Country:US
Practice Address - Phone:628-234-5200
Practice Address - Fax:618-234-4400
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL627824OtherULTC
IL900068033OtherESSENCE
ILP00110676OtherMEDICARE RR
ILL98414Medicare ID - Type Unspecified
ILU85290Medicare UPIN