Provider Demographics
NPI:1336297993
Name:BIDLACK, GREGORY (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BIDLACK
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 1:17617 N 9TH ST
Mailing Address - Street 2:#1099
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-1935
Mailing Address - Country:US
Mailing Address - Phone:480-217-9527
Mailing Address - Fax:
Practice Address - Street 1:18775 N REEMS RD
Practice Address - Street 2:STE 360
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-8647
Practice Address - Country:US
Practice Address - Phone:623-544-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3222111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0944530OtherBCBS
AZT41400Medicare UPIN
AZ103434Medicare ID - Type UnspecifiedMEDICARE