Provider Demographics
NPI:1538119888
Name:WEBER, SCOTT T (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:WEBER
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 1:1807 W LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1008
Mailing Address - Country:US
Mailing Address - Phone:217-243-5438
Mailing Address - Fax:217-243-3535
Practice Address - Street 1:1807 W LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1008
Practice Address - Country:US
Practice Address - Phone:217-243-5438
Practice Address - Fax:217-243-3535
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007815Medicaid
IL208387Medicare ID - Type Unspecified
ILK27868OtherMEDICARE PTAN