Provider Demographics
NPI:1619151776
Name:NIEHAUS, DEREK A (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:A
Last Name:NIEHAUS
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 1:1002 SPOTSYLVANIA STREET
Mailing Address - Street 2:
Mailing Address - City:NEW ATHENS
Mailing Address - State:IL
Mailing Address - Zip Code:62264-1597
Mailing Address - Country:US
Mailing Address - Phone:618-475-3600
Mailing Address - Fax:
Practice Address - Street 1:1002 SPOTSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:NEW ATHENS
Practice Address - State:IL
Practice Address - Zip Code:62264-1597
Practice Address - Country:US
Practice Address - Phone:618-475-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV07373Medicare UPIN