Provider Demographics
NPI:1881795870
Name:BROOM, GARY DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DAVID
Last Name:BROOM
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 1:1820 WINDSOR RD
Mailing Address - Street 2:SUIT A
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4271
Mailing Address - Country:US
Mailing Address - Phone:815-986-4411
Mailing Address - Fax:815-986-4414
Practice Address - Street 1:1820 WINDSOR RD
Practice Address - Street 2:SUIT A
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4271
Practice Address - Country:US
Practice Address - Phone:815-986-4411
Practice Address - Fax:815-986-4414
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008602111N00000X
IL038008602111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL528320Medicare ID - Type Unspecified
ILU73389Medicare UPIN