Provider Demographics
NPI:1982770681
Name:PONTARELLI, MICHAEL ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:PONTARELLI
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 1:620 N CARLYLE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-5751
Mailing Address - Country:US
Mailing Address - Phone:847-754-1946
Mailing Address - Fax:773-235-7894
Practice Address - Street 1:1811 W NORTH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-0202
Practice Address - Country:US
Practice Address - Phone:773-235-7878
Practice Address - Fax:773-235-7894
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634086OtherBLUE CROSS BLUE SHIELD