Provider Demographics
NPI:1790891273
Name:ZIMMERMAN, RICHARD W (DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:ZIMMERMAN
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 1:7 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1420
Mailing Address - Country:US
Mailing Address - Phone:618-542-2165
Mailing Address - Fax:
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1420
Practice Address - Country:US
Practice Address - Phone:618-542-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07308609OtherBLUE CROSS BLUE SHIELD
IL038007421Medicaid
IL038007421Medicaid
ILU51517Medicare UPIN