Provider Demographics
NPI:1750460721
Name:TATTERSALL, RAYMOND C (DC)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:C
Last Name:TATTERSALL
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 1:309 S KALAMAZOO ST
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1527
Mailing Address - Country:US
Mailing Address - Phone:269-657-7005
Mailing Address - Fax:269-657-7007
Practice Address - Street 1:309 S KALAMAZOO ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1527
Practice Address - Country:US
Practice Address - Phone:269-657-7005
Practice Address - Fax:269-657-7007
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1935037Medicaid
MA95OHO5002OtherBCBS
MA2301004320OtherLICENSE
MA95OHO5002OtherBCBS
MIU11237Medicare UPIN