Provider Demographics
NPI:1831246230
Name:SIDDIQUI, REHAN (DC)
Entity type:Individual
Prefix:
First Name:REHAN
Middle Name:
Last Name:SIDDIQUI
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 1:3043 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2807
Mailing Address - Country:US
Mailing Address - Phone:773-862-3180
Mailing Address - Fax:773-661-0300
Practice Address - Street 1:3043 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2807
Practice Address - Country:US
Practice Address - Phone:773-862-3180
Practice Address - Fax:773-661-0300
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008564111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001622785OtherBCBS PROVIDER #
IL038008564Medicaid
IL001622785OtherBCBS PROVIDER #