Basic Information
| Provider Information | |||||||||
| NPI: | 1881851780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLERY | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C., M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 N. ROCKTON AVE | ||||||||
| Address2: | ROCKFORD HEALTH PHYSICIANS | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2350 N. ROCKTON AVE | ||||||||
| Address2: | ROCKFORD HEALTH PHYSICIANS | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038007829 | IL | N | Chiropractic Providers | Chiropractor | 2084N0400X | 125055297 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.