Provider Demographics
NPI:1518068337
Name:LYELL, PAUL G (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:G
Last Name:LYELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:G
Other - Last Name:LYELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1521 W WALNUT ST STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1153
Mailing Address - Country:US
Mailing Address - Phone:217-243-4333
Mailing Address - Fax:844-892-4533
Practice Address - Street 1:1521 W WALNUT ST STE D
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1153
Practice Address - Country:US
Practice Address - Phone:217-243-4333
Practice Address - Fax:217-243-8082
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017018593111N00000X
CADC-30710111N00000X
IL38010780111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038010780OtherSTATE LICENSE
IL770755OtherHEALINLINK PROVIDER#
CADC-30710OtherSTATE LICENSE
IL07521142OtherBCBS OF IL
CADC-30710OtherCALIFORNIA STATE LIC.
IL038010780OtherSTATE LICENSE
ILV10349Medicare UPIN