MEDICARE: SAMPLE CHIROPRACTIC

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	DC006142L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036524LGY	OTHER	PA	MEDICARE PROVIDER NUMBER

General Provider Information

NPI Number	:	1205019130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMPLE CHIROPRACTIC

Provider Business Mailing Address
First Line	:	PO BOX 1566
Second Line	:
City	:	MONROEVILLE
State	:	PA
Zip	:	15146-9566
Country	:	US
Telephone Number	:	724-387-2667
Fax Number	:	724-387-2667

Provider Business Practice Location Address
First Line	:	751 PITTSBURGH MCKEESPORT BLVD
Second Line	:
City	:	DRAVOSBURG
State	:	PA
Zip	:	15034-1065
Country	:	US
Telephone Number	:	412-469-1078
Fax Number	:	412-469-0823

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. WILLIAM R SAMPLE
Credential	:	D.C.
Telephone Number	:	412-469-0823

Provider Enumeration Date	:	12/13/2007
Last Update Date	:	12/13/2007

Similar Medicare Providers

1174077655 — MRS. DANELLE COYNE MSW
Practice Location Address:

751 PITTSBURGH MCKEESPORT BLVD
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15034-1065

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1831134709 — PIERCE CHIROPRACTIC CLINIC
Practice Location Address:

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1437195930 — PRO ADJUSTER REHABILITATION
Practice Location Address:

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15034-1012

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1831124627 — DR. C. HERBERT WILLSON III DC
Practice Location Address:

209 RICHLAND AVE
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15034-1160

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1043446214 — DR. KYLE ARCHER WALK D.M.D.
Practice Location Address:

510 RICHLAND AVE
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1053639252 — AN ANSWERED PRAYER
Practice Location Address:

25 SCOTT DR , E
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Practice Fax:

Directions to “SAMPLE CHIROPRACTIC ” Practice Location

Language	Start Address	Practice Location

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