Provider Demographics
NPI:1720040694
Name:KOTSCHEVAR, PAMELA JEAN (DC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:KOTSCHEVAR
Suffix:
Gender:F
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:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-0464
Mailing Address - Country:US
Mailing Address - Phone:217-532-9461
Mailing Address - Fax:217-532-9461
Practice Address - Street 1:114 E WOOD ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1526
Practice Address - Country:US
Practice Address - Phone:217-532-9461
Practice Address - Fax:217-532-9461
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06800058OtherBLUECROSS/BLUESHIELD
IL06800058OtherBLUECROSS/BLUESHIELD
T38555Medicare UPIN