MEDICARE: DR. JASON C THEOBALD 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	3855-012	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CB3715	OTHER	WI	RAILROAD MEDICARE GROUP
4	350056012	OTHER	WI	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962509604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON C THEOBALD DC

Provider Business Mailing Address
First Line	:	550 W MAPLE ST
Second Line	:	SUITE # 201
City	:	BARABOO
State	:	WI
Zip	:	53913-1166
Country	:	US
Telephone Number	:	608-355-4100
Fax Number	:	608-355-4107

Provider Business Practice Location Address
First Line	:	550 W MAPLE ST
Second Line	:
City	:	BARABOO
State	:	WI
Zip	:	53913-1166
Country	:	US
Telephone Number	:	608-355-4100
Fax Number	:	608-355-4107

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	01/20/2016

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Directions to “ DR. JASON C THEOBALD DC” Practice Location

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