Provider Demographics
NPI:1306053418
Name:GROTHMAN, M. WARNER (DC)
Entity type:Individual
Prefix:DR
First Name:M.
Middle Name:WARNER
Last Name:GROTHMAN
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 1:1460 WILMETTE ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3712
Mailing Address - Country:US
Mailing Address - Phone:630-665-4177
Mailing Address - Fax:
Practice Address - Street 1:845 N LAKE ST STE 1
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3178
Practice Address - Country:US
Practice Address - Phone:630-844-1244
Practice Address - Fax:630-844-1199
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4515209OtherBCBS OF IL
IL1710986179OtherCLINIC NPI
IL1710986179OtherCLINIC NPI