Provider Demographics
NPI:1356488241
Name:GEREGA, EDVARD LC (DC)
Entity Type:Individual
Prefix:DR
First Name:EDVARD
Middle Name:LC
Last Name:GEREGA
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 1:1013 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252-1715
Mailing Address - Country:US
Mailing Address - Phone:815-589-3291
Mailing Address - Fax:815-589-3291
Practice Address - Street 1:1013 4TH STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IL
Practice Address - Zip Code:61252-1715
Practice Address - Country:US
Practice Address - Phone:815-589-3291
Practice Address - Fax:815-589-3291
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006218111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002906967OtherBCBS
U06120Medicare UPIN
933500Medicare ID - Type Unspecified