Provider Demographics
NPI:1326006396
Name:SAMPLE, MICHAEL W (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:DAWN
Other - Middle Name:M
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:51 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1534
Mailing Address - Country:US
Mailing Address - Phone:815-468-7787
Mailing Address - Fax:815-468-0154
Practice Address - Street 1:51 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1534
Practice Address - Country:US
Practice Address - Phone:815-468-7787
Practice Address - Fax:815-468-0154
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
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
IL4619978OtherBC/BS PROVIDER NUMBER
ILU54064Medicare UPIN
IL361360Medicare ID - Type UnspecifiedMEDICARE #
IL361350Medicare ID - Type UnspecifiedOFFICE ID