Provider Demographics
NPI:1861575227
Name:PRIDEMORE, THOMAS JEFFERSON JR (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JEFFERSON
Last Name:PRIDEMORE
Suffix:JR
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:PO BOX 893
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0893
Mailing Address - Country:US
Mailing Address - Phone:309-333-9264
Mailing Address - Fax:
Practice Address - Street 1:109 S JOHNSON ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2134
Practice Address - Country:US
Practice Address - Phone:309-333-9264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05532009OtherBLUECROSS/BLUESHIELD ID
IL038009915Medicaid
IL207979Medicare ID - Type Unspecified
ILK02962Medicare PIN
ILU98116Medicare UPIN