MEDICARE: DR. THEODORE R HERAZY 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		IL

General Provider Information

NPI Number	:	1871715458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE R HERAZY D.C.

Provider Business Mailing Address
First Line	:	1933 N EVERGREEN AVE
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3173
Country	:	US
Telephone Number	:	847-873-8888
Fax Number	:	847-670-8800

Provider Business Practice Location Address
First Line	:	504 N PLUM GROVE RD
Second Line	:	SUITE C
City	:	PALATINE
State	:	IL
Zip	:	60067-8207
Country	:	US
Telephone Number	:	847-358-0010
Fax Number	:	847-358-8244

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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