Provider Demographics
NPI:1821028937
Name:MCGUCKIN, BRIAN CHARLES (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:MCGUCKIN
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:PO BOX 8907
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46361-8907
Mailing Address - Country:US
Mailing Address - Phone:219-531-1234
Mailing Address - Fax:219-531-0476
Practice Address - Street 1:412 MARQUETTE ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2563
Practice Address - Country:US
Practice Address - Phone:219-531-1234
Practice Address - Fax:219-531-0476
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001021A111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000019695OtherANTHEM PROVIDER
IN163140Medicare ID - Type UnspecifiedCORPORATE MEDICARE IDENTI
IN00000019695OtherANTHEM PROVIDER
INT81867Medicare UPIN