Provider Demographics
NPI:1376542480
Name:PECK, ANTHONY W (DC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:W
Last Name:PECK
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 1:1601 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1622
Mailing Address - Country:US
Mailing Address - Phone:618-628-8882
Mailing Address - Fax:618-628-8856
Practice Address - Street 1:1601 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1622
Practice Address - Country:US
Practice Address - Phone:618-628-8882
Practice Address - Fax:618-628-8856
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2013-11-07
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IL038-008515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL573950Medicare PIN
ILU71972Medicare UPIN