MEDICARE: KIPP L CHILLAG DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0008X	Pediatric Neurodevelopmental Disabilities Physician	51010114017	MI
2	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	5101014017	MI
3	2084N0400X	Neurology Physician	5101014017	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H400493386	OTHER	MN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518931245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIPP L CHILLAG DO

Provider Business Mailing Address
First Line	:	PO BOX 1848
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49443-1848
Country	:	US
Telephone Number	:	231-672-4243
Fax Number	:	231-727-4214

Provider Business Practice Location Address
First Line	:	1675 LEAHY ST STE 401A
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5547
Country	:	US
Telephone Number	:	231-672-4243
Fax Number	:	231-727-4214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	09/13/2021

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Directions to “ KIPP L CHILLAG DO” Practice Location

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