Healthcare Provider Details

I. General information

NPI: 1235845496
Provider Name (Legal Business Name): KEITH PRIDGEON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHAUN PRIDGEON

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S MICHIGAN AVE STE 104
CHICAGO IL
60616-2857
US

IV. Provider business mailing address

354 MERRIMACK ST STE 395
LAWRENCE MA
01843-1755
US

V. Phone/Fax

Practice location:
  • Phone: 774-206-1125
  • Fax:
Mailing address:
  • Phone: 774-206-1125
  • Fax: 774-628-9657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: