Provider Demographics
NPI:1699894287
Name:JOHN R WASEM DC PC
Entity type:Organization
Organization Name:JOHN R WASEM DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WASEM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-428-2322
Mailing Address - Street 1:1358 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3737
Mailing Address - Country:US
Mailing Address - Phone:217-428-2322
Mailing Address - Fax:217-428-1170
Practice Address - Street 1:1358 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3737
Practice Address - Country:US
Practice Address - Phone:217-428-2322
Practice Address - Fax:217-428-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCHIROPRACTOR111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005821789OtherBLUE CROSS BLUE SHIELD
IL285020Medicare ID - Type Unspecified
ILT35974Medicare UPIN