Provider Demographics
NPI:1477629202
Name:WHITAKER, PATRICK B (DC PC)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:B
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DC PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S PHELPS AVENUE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-229-5568
Mailing Address - Fax:815-229-0942
Practice Address - Street 1:129 S PHELPS AVENUE
Practice Address - Street 2:SUITE 316
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-229-5568
Practice Address - Fax:815-229-0942
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
573360Medicare ID - Type Unspecified
T37426Medicare UPIN