MEDICARE: DR. GARY DAVID BROOM D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038-008602	IL
2	111NS0005X	Sports Physician Chiropractor	038008602	IL

General Provider Information

NPI Number	:	1881795870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY DAVID BROOM D.C.

Provider Business Mailing Address
First Line	:	1820 WINDSOR RD
Second Line	:	SUIT A
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4271
Country	:	US
Telephone Number	:	815-986-4411
Fax Number	:	815-986-4414

Provider Business Practice Location Address
First Line	:	1820 WINDSOR RD
Second Line	:	SUIT A
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4271
Country	:	US
Telephone Number	:	815-986-4411
Fax Number	:	815-986-4414

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	03/31/2009

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