Provider Demographics
NPI:1730172636
Name:WIEGAND, MARK J (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WIEGAND
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:926 BROADWAY ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2748
Mailing Address - Country:US
Mailing Address - Phone:217-222-5100
Mailing Address - Fax:217-222-5178
Practice Address - Street 1:926 BROADWAY ST
Practice Address - Street 2:SUITE 4
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2748
Practice Address - Country:US
Practice Address - Phone:217-222-5100
Practice Address - Fax:217-222-5178
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU88488Medicare UPIN
IL209273Medicare ID - Type Unspecified