MEDICARE: GLADSTONE CHIROPRACTIC GROUP LTD

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	038008327	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1630133	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1376766600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLADSTONE CHIROPRACTIC GROUP LTD

Provider Business Mailing Address
First Line	:	5316 B N MILWAUKEE AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1266
Country	:	US
Telephone Number	:	773-774-1041
Fax Number	:	773-774-8541

Provider Business Practice Location Address
First Line	:	5316 B N MILWAUKEE AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1266
Country	:	US
Telephone Number	:	773-774-1041
Fax Number	:	773-774-8541

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELIZABETH STIPISIC
Credential	:	DC
Telephone Number	:	773-774-1041

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	06/24/2008

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