Provider Demographics
NPI:1902987324
Name:WECKBACH, ROBERT T (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:WECKBACH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 MAINE STREET
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301
Mailing Address - Country:US
Mailing Address - Phone:217-222-4399
Mailing Address - Fax:217-222-0480
Practice Address - Street 1:422 MAINE STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301
Practice Address - Country:US
Practice Address - Phone:217-222-4399
Practice Address - Fax:217-222-0480
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038004861Medicaid
IL350042367OtherRR MEDICARE
IL0000182012OtherBLUE CROSS / BLUE SHIELD
IL038004861Medicaid