Provider Demographics
NPI:1871664086
Name:MEDLIN, MARK W (DC,BS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:MEDLIN
Suffix:
Gender:M
Credentials:DC,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 E STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1884
Mailing Address - Country:US
Mailing Address - Phone:317-398-9355
Mailing Address - Fax:
Practice Address - Street 1:2517 E STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1884
Practice Address - Country:US
Practice Address - Phone:317-398-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001803A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20018200AMedicaid
INU75933Medicare UPIN
IN138990Medicare ID - Type Unspecified