Provider Demographics
NPI:1639474570
Name:DAVIDSON, PHILIP WESLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:WESLEY
Last Name:DAVIDSON
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 1:5334 HENRY COURT
Mailing Address - Street 2:APT B
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-6023
Mailing Address - Country:US
Mailing Address - Phone:224-456-6284
Mailing Address - Fax:
Practice Address - Street 1:5334 HENRY COURT
Practice Address - Street 2:APT B
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-6023
Practice Address - Country:US
Practice Address - Phone:224-456-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211141001Medicare PIN