Provider Demographics
NPI:1538135744
Name:MATHEIS, STEPHEN EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:MATHEIS
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 1:2819 19TH STREET
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244
Mailing Address - Country:US
Mailing Address - Phone:309-792-9710
Mailing Address - Fax:309-792-9710
Practice Address - Street 1:2819 19TH ST
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244
Practice Address - Country:US
Practice Address - Phone:309-792-9710
Practice Address - Fax:309-792-9710
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
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
T38719Medicare UPIN
763670Medicare ID - Type Unspecified