MEDICARE: DYNAMIC SPINE AND JOINT CENTER LLC

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

General Provider Information

NPI Number	:	1578860664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC SPINE AND JOINT CENTER LLC

Provider Business Mailing Address
First Line	:	3000 IOWA ST
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4926
Country	:	US
Telephone Number	:	618-219-5344
Fax Number	:

Provider Business Practice Location Address
First Line	:	4917 MARYVILLE RD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-2644
Country	:	US
Telephone Number	:	618-219-5344
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROSS TYLER
Credential	:	DC
Telephone Number	:	618-219-5344

Provider Enumeration Date	:	02/25/2011
Last Update Date	:	03/11/2011

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