Provider Demographics
NPI:1104922574
Name:GEORGES, TODD
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:GEORGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N. STATE STREET
Mailing Address - Street 2:
Mailing Address - City:RIDGE FARM
Mailing Address - State:IL
Mailing Address - Zip Code:61870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N. STATE STREET
Practice Address - Street 2:
Practice Address - City:RIDGE FARM
Practice Address - State:IL
Practice Address - Zip Code:61870
Practice Address - Country:US
Practice Address - Phone:217-247-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009232002OtherBLUE CROSS BLUE
IL364260Medicare ID - Type Unspecified
IL0009232002OtherBLUE CROSS BLUE