Provider Demographics
NPI:1679634323
Name:TYRELL, DAVID S (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:TYRELL
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 1:4321 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1815
Mailing Address - Country:US
Mailing Address - Phone:773-736-7484
Mailing Address - Fax:
Practice Address - Street 1:4321 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1815
Practice Address - Country:US
Practice Address - Phone:773-736-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006414111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001682359OtherBCBS
IL908500Medicare ID - Type Unspecified