Provider Demographics
NPI:1700845047
Name:ETHEN, JOSEPH JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:ETHEN
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 1:662 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1694
Mailing Address - Country:US
Mailing Address - Phone:847-835-4700
Mailing Address - Fax:847-835-8408
Practice Address - Street 1:662 VERNON AVE
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022-1694
Practice Address - Country:US
Practice Address - Phone:847-835-4700
Practice Address - Fax:847-835-8408
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011678111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2638686Medicaid
OH2867938OtherMEDICAID GROUP NUMBER
OH9358811OtherMEDICARE GROUP NUMBER
OH2638686Medicaid