Basic Information
| Provider Information | |||||||||
| NPI: | 1730484783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIROTINSKIY | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7711 W 159TH ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604771329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085328080 | ||||||||
| FaxNumber: | 7085328383 | ||||||||
| Practice Location | |||||||||
| Address1: | 13657 CICERO AVE | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604451936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083962500 | ||||||||
| FaxNumber: | 7083968605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2011 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038-011871 | IL | Y | Chiropractic Providers | Chiropractor |
No ID Information.