Provider Demographics
NPI:1497811541
Name:SUTTON, MICHAEL PHILIP (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILIP
Last Name:SUTTON
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 1:4855 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2274
Mailing Address - Country:US
Mailing Address - Phone:815-226-1405
Mailing Address - Fax:815-398-8132
Practice Address - Street 1:4855 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2274
Practice Address - Country:US
Practice Address - Phone:815-226-1405
Practice Address - Fax:815-398-8132
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
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
ILP00119875OtherRR MEDICARE
IL001B9OtherECOH
IL10182028OtherBLUE CROSS BLUE SHIELD
ILP00119875OtherRR MEDICARE
IL608080Medicare ID - Type Unspecified