Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | IL | |
N | 111NR0400X | Rehabilitation Chiropractor | IL |
NPI | 1124236989 |
---|---|
Provider Name | Ms. Susan Marie Minder |
First Address | Springfield, IL 62704-4190 |
Second Address | Springfield, IL 62704-4190 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
339643 | HEALTH LINK (01) | |
84-20187 | BLUE CROSS & BLUE SHIELD (01) | |
U67334 | (02) |