Provider Demographics
NPI:1457485906
Name:ZIMMERMAN, GREGORY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LYNN
Last Name:ZIMMERMAN
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 1:119 S BATAVIA AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2450
Mailing Address - Country:US
Mailing Address - Phone:630-482-2214
Mailing Address - Fax:630-879-2347
Practice Address - Street 1:119 S BATAVIA AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2450
Practice Address - Country:US
Practice Address - Phone:630-482-2214
Practice Address - Fax:630-879-2347
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03800924111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09123588OtherBLUE CROSS BLUE SHIELD IL
ILL76355Medicare ID - Type UnspecifiedMEDICARE PROVIDER
ILU79119Medicare UPIN
IL572720Medicare ID - Type UnspecifiedMEDICARE GROUP