MEDICARE: DR. MARK E. WERTZ 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	038011510	IL

General Provider Information

NPI Number	:	1164758314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK E. WERTZ D.C.

Provider Business Mailing Address
First Line	:	3105 VILLAGE OFFICE PL
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7673
Country	:	US
Telephone Number	:	217-352-9108
Fax Number	:	217-352-9105

Provider Business Practice Location Address
First Line	:	3105 VILLAGE OFFICE PL
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7673
Country	:	US
Telephone Number	:	217-352-9108
Fax Number	:	217-352-9105

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

Provider Enumeration Date	:	10/22/2009
Last Update Date	:	12/09/2014

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