Provider Demographics
NPI:1457348740
Name:HERRICK, MICHAEL JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:HERRICK
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 1:1914 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3953
Mailing Address - Country:US
Mailing Address - Phone:309-762-1002
Mailing Address - Fax:309-736-3484
Practice Address - Street 1:1914 16TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3953
Practice Address - Country:US
Practice Address - Phone:309-762-1002
Practice Address - Fax:309-736-3484
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010214111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038010214Medicaid
K52432OtherMEDICARE PTAN
IA0590992Medicaid
IL038010214Medicaid