MEDICARE: QUIRAM SPINAL & SPORTS REHABILITATION 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	111NR0400X	Rehabilitation Chiropractor	042-617717	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5732002	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1780760413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUIRAM SPINAL & SPORTS REHABILITATION LTD

Provider Business Mailing Address
First Line	:	21108 N 25 EAST ROAD
Second Line	:
City	:	DANVERS
State	:	IL
Zip	:	61732-4497
Country	:	US
Telephone Number	:	309-662-6462
Fax Number	:	309-965-2384

Provider Business Practice Location Address
First Line	:	21108 N 25 EAST ROAD
Second Line	:
City	:	DANVERS
State	:	IL
Zip	:	61732-4497
Country	:	US
Telephone Number	:	309-662-6462
Fax Number	:	309-965-2384

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. LESLIE R QUIRAM
Credential	:	D.C.
Telephone Number	:	309-662-6462

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	08/05/2009

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