MEDICARE: DR. DAVID S TYRELL DC

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	038006414	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001682359	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1679634323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID S TYRELL DC

Provider Business Mailing Address
First Line	:	4321 N CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1815
Country	:	US
Telephone Number	:	773-736-7484
Fax Number	:

Provider Business Practice Location Address
First Line	:	4321 N CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1815
Country	:	US
Telephone Number	:	773-736-7484
Fax Number	:

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	01/22/2010

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