Provider Demographics
NPI:1679586747
Name:DEWASME, ANDREA MARIE
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:DEWASME
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:M
Other - Last Name:BUCKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:815 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2345
Mailing Address - Country:US
Mailing Address - Phone:815-416-1132
Mailing Address - Fax:815-416-1135
Practice Address - Street 1:1526 CREEK DR
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-6862
Practice Address - Country:US
Practice Address - Phone:815-416-1132
Practice Address - Fax:815-416-1135
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009326111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3232011OtherBLUE CROSS BLUE SHIELD
IL3232011OtherBLUE CROSS BLUE SHIELD
IL210556Medicare ID - Type Unspecified