Provider Demographics
NPI:1841216736
Name:PEFFER, MICHAEL ROBERT (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:PEFFER
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 1:118 WESTSHORE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1315
Mailing Address - Country:US
Mailing Address - Phone:309-397-4134
Mailing Address - Fax:
Practice Address - Street 1:1014 EKSTAM DR STE 104
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6382
Practice Address - Country:US
Practice Address - Phone:309-661-0414
Practice Address - Fax:309-661-8697
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006953111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732069OtherBLUE CROSS BLUE SHIELD
IL5732069OtherBLUE CROSS BLUE SHIELD