Provider Demographics
NPI:1780780635
Name:FOURDYCE, ANTHONY WEBSTER (DC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WEBSTER
Last Name:FOURDYCE
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 1:1600 VANDALIA SE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4459
Mailing Address - Country:US
Mailing Address - Phone:618-344-0071
Mailing Address - Fax:618-344-0095
Practice Address - Street 1:1600 VANDALIA SE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4459
Practice Address - Country:US
Practice Address - Phone:618-344-0071
Practice Address - Fax:618-344-0095
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
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
IL232740Medicare ID - Type Unspecified