Healthcare Provider Details

I. General information

NPI: 1649779471
Provider Name (Legal Business Name): KRISTOPHER BRIDGEMAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 ESSINGTON RD
JOLIET IL
60435-8439
US

IV. Provider business mailing address

951 ESSINGTON RD
JOLIET IL
60435-8439
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-4551
  • Fax: 815-744-4756
Mailing address:
  • Phone: 815-744-4551
  • Fax: 815-744-4756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: