Provider Demographics
NPI:1053850032
Name:DEROSIA, TYLER (DC, ATC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:DEROSIA
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2221
Mailing Address - Country:US
Mailing Address - Phone:737-293-7777
Mailing Address - Fax:
Practice Address - Street 1:11001 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2221
Practice Address - Country:US
Practice Address - Phone:773-239-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013850111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor