Provider Demographics
NPI:1972553410
Name:WADE, MARK W (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:WADE
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 1:295 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1301
Mailing Address - Country:US
Mailing Address - Phone:217-854-8211
Mailing Address - Fax:217-854-3636
Practice Address - Street 1:295 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1301
Practice Address - Country:US
Practice Address - Phone:217-854-8211
Practice Address - Fax:217-854-3636
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
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
IL0005982011OtherBLUECROSS BLUESHIELD
IL0005982011OtherBLUECROSS BLUESHIELD