Provider Demographics
NPI:1326193533
Name:GARY, EDWARD J (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:GARY
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 1:201 N JACKSON
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056
Mailing Address - Country:US
Mailing Address - Phone:217-324-6424
Mailing Address - Fax:217-324-6424
Practice Address - Street 1:201 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-2009
Practice Address - Country:US
Practice Address - Phone:217-324-6424
Practice Address - Fax:217-324-6424
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003368111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038003368Medicaid
T36080Medicare UPIN
IL038003368Medicaid