Provider Demographics
NPI:1952356578
Name:DYKEMAN, ANDREW W (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:W
Last Name:DYKEMAN
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 1:33 EAST AIRLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024
Mailing Address - Country:US
Mailing Address - Phone:618-259-2676
Mailing Address - Fax:618-259-2679
Practice Address - Street 1:33 EAST AIRLINE DRIVE
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024
Practice Address - Country:US
Practice Address - Phone:618-259-2676
Practice Address - Fax:618-259-2679
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2012-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010073111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038010073Medicaid
IL664129OtherUHC
IL6032097OtherBCBS
U98200Medicare UPIN
IL038010073Medicaid