=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023130077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSIDE CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 11/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3250 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-755-9515
-----------------------------------------------------
Fax | 773-755-9517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3250 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-755-9515
-----------------------------------------------------
Fax | 773-755-9517
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL JAMES DUBICK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 773-755-9515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038008549
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------