Healthcare Provider Details

I. General information

NPI: 1629346812
Provider Name (Legal Business Name): CHESTER MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 OLD PLANK RD
CHESTER IL
62233-1153
US

IV. Provider business mailing address

2319 OLD PLANK RD
CHESTER IL
62233-1153
US

V. Phone/Fax

Practice location:
  • Phone: 618-826-2388
  • Fax: 618-826-3350
Mailing address:
  • Phone: 618-826-2388
  • Fax: 618-826-5798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DONNA MARTIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-826-2388