Provider Demographics
NPI:1093760183
Name:GOSSETT, TOMMY KEITH (DC)
Entity type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:KEITH
Last Name:GOSSETT
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 1:2009 FOX DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7363
Mailing Address - Country:US
Mailing Address - Phone:217-351-8040
Mailing Address - Fax:217-239-5983
Practice Address - Street 1:2009 FOX DRIVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7364
Practice Address - Country:US
Practice Address - Phone:217-351-8040
Practice Address - Fax:217-239-5983
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001082016OtherBSBC PROVIDER #
IL1093760183OtherNPI #
IL350001628OtherRAILROAD MEDICARE PROV#
IL0001082016OtherBSBC PROVIDER #
IL609980Medicare ID - Type UnspecifiedPROVIDER NUMBER