MEDICARE: DR. JOHN RUCKS ROSSER JR. 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	038003342	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4515124	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1164471264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN RUCKS ROSSER JR. D.C.

Provider Business Mailing Address
First Line	:	1276 W SPRING ST
Second Line	:
City	:	SOUTH ELGIN
State	:	IL
Zip	:	60177-3304
Country	:	US
Telephone Number	:	847-741-6400
Fax Number	:	847-741-6926

Provider Business Practice Location Address
First Line	:	1276 W SPRING ST
Second Line	:
City	:	SOUTH ELGIN
State	:	IL
Zip	:	60177-3304
Country	:	US
Telephone Number	:	847-741-6400
Fax Number	:	847-741-6926

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	01/22/2014

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