Provider Demographics
NPI:1104144187
Name:CHESTER CLINIC PROFESSIONAL CORP.
Entity type:Organization
Organization Name:CHESTER CLINIC PROFESSIONAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-965-3382
Mailing Address - Street 1:602 W SHAWNEETOWN TRL
Mailing Address - Street 2:
Mailing Address - City:STEELEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62288-1126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 W SHAWNEETOWN TRL
Practice Address - Street 2:
Practice Address - City:STEELEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62288-1126
Practice Address - Country:US
Practice Address - Phone:618-965-3382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTER CLINIC PROFESSIONAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-14
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
962310OtherMEDICARE
962310OtherMEDICARE