Provider Demographics
NPI:1568576114
Name:STAM, DOUGLAS M (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:STAM
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 1:396 BELLE AIRE AVE
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2010
Mailing Address - Country:US
Mailing Address - Phone:815-933-7391
Mailing Address - Fax:
Practice Address - Street 1:396 BELLE AIRE AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2010
Practice Address - Country:US
Practice Address - Phone:815-933-7391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004682104OtherBC/BS NUMBER
IL609290Medicare ID - Type Unspecified
ILT37217Medicare UPIN