Provider Demographics
NPI:1063518090
Name:PHELAN, JOHN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PHELAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-1413
Mailing Address - Country:US
Mailing Address - Phone:574-772-5771
Mailing Address - Fax:574-772-7715
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-1413
Practice Address - Country:US
Practice Address - Phone:574-772-5771
Practice Address - Fax:574-772-7715
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000997A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200071670AMedicaid
INT85592Medicare UPIN