=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336297993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY BIDLACK DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 09/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18775 N REEMS RD STE 360
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-8647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-544-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17617 N 9TH ST #1099
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85022-1935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-217-9527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3222
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------