Provider Demographics
NPI:1902010424
Name:STINE, MARK H (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:STINE
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 1:315 CHATHAM RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1497
Mailing Address - Country:US
Mailing Address - Phone:217-741-3168
Mailing Address - Fax:
Practice Address - Street 1:315 CHATHAM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1497
Practice Address - Country:US
Practice Address - Phone:217-741-3168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU81278Medicare UPIN