Provider Demographics
NPI:1457320830
Name:WESELY, MARK M (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:WESELY
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 1:800 ROOSEVELT RD
Mailing Address - Street 2:BLDG B SUITE 112
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5839
Mailing Address - Country:US
Mailing Address - Phone:630-790-3335
Mailing Address - Fax:630-790-3345
Practice Address - Street 1:800 ROOSEVELT RD
Practice Address - Street 2:BLDG B SUITE 112
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5839
Practice Address - Country:US
Practice Address - Phone:630-790-3335
Practice Address - Fax:630-790-3345
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232331OtherBCBSIL
IL02232331OtherBCBSIL