Provider Demographics
NPI:1356457873
Name:FITZSIMMONS, MARY MELISSA (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MELISSA
Last Name:FITZSIMMONS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-1236
Mailing Address - Country:US
Mailing Address - Phone:815-476-3700
Mailing Address - Fax:815-476-1067
Practice Address - Street 1:300 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60481-1236
Practice Address - Country:US
Practice Address - Phone:815-476-3700
Practice Address - Fax:815-476-1067
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009926858OtherBLUE CROSS/BLUE SHIELD
ILU82240Medicare UPIN
ILK45815Medicare PIN