Provider Demographics
NPI:1780747428
Name:THIRY, ROBERT T (DC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:T
Last Name:THIRY
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:PO BOX 3047
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-8047
Mailing Address - Country:US
Mailing Address - Phone:612-695-4890
Mailing Address - Fax:
Practice Address - Street 1:1608 W 155TH ST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-5308
Practice Address - Country:US
Practice Address - Phone:612-695-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29064THOtherBLUE CROSS BLUE SHIELD
MN350610864Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
MNCO4418Medicare PIN