Provider Demographics
NPI:1699774190
Name:CONDON, MICHAEL JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:CONDON
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 1:806 W DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1602
Mailing Address - Country:US
Mailing Address - Phone:815-664-4858
Mailing Address - Fax:815-664-2135
Practice Address - Street 1:806 W DAKOTA ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1602
Practice Address - Country:US
Practice Address - Phone:815-664-4858
Practice Address - Fax:815-664-2135
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
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
IL00621412OtherBLUE CROSS BLUE SHIELD
IL00621412OtherBLUE CROSS BLUE SHIELD
ILU55320Medicare UPIN