MEDICARE: DR. PETER D CROCKER 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	5854	AZ
2	111N00000X	Chiropractor	038012184	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2194521	OTHER	AZ	FIRST HEALTH
2	2050841	OTHER	AZ	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1437169851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER D CROCKER D.C.

Provider Business Mailing Address
First Line	:	PO BOX 97
Second Line	:
City	:	PORT BYRON
State	:	IL
Zip	:	61275-0097
Country	:	US
Telephone Number	:	309-848-9017
Fax Number	:	888-830-9748

Provider Business Practice Location Address
First Line	:	106 N HIGH ST
Second Line	:
City	:	PORT BYRON
State	:	IL
Zip	:	61275-9532
Country	:	US
Telephone Number	:	309-848-9017
Fax Number	:	888-830-9748

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/09/2012

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