Healthcare Provider Details

I. General information

NPI: 1043597610
Provider Name (Legal Business Name): CHESTER MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W SHAWNEETOWN TRL
STEELEVILLE IL
62288-1126
US

IV. Provider business mailing address

602 W SHAWNEETOWN TRL
STEELEVILLE IL
62288-1126
US

V. Phone/Fax

Practice location:
  • Phone: 618-965-3382
  • Fax:
Mailing address:
  • Phone: 618-965-3382
  • Fax:

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