Provider Demographics
NPI:1841347812
Name:SELVIDGE, WILLIAM SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:SCOTT
Last Name:SELVIDGE
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 1:608 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4321
Mailing Address - Country:US
Mailing Address - Phone:217-235-4664
Mailing Address - Fax:217-235-2100
Practice Address - Street 1:608 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4321
Practice Address - Country:US
Practice Address - Phone:217-235-4664
Practice Address - Fax:217-235-2100
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008622111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038008622Medicaid
IL44-03304OtherUNITED HEALTHCARE
IL06022634OtherBCBS OF IL
IL9086460OtherPRIVATE HEALTHCARE SYSTEM
IL407016OtherHEALTHLINK
IL06022634OtherBCBS OF IL