Provider Demographics
NPI:1043805930
Name:CHESTNUT MEDICINE OF WI LTD
Entity Type:Organization
Organization Name:CHESTNUT MEDICINE OF WI LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OMAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-964-8199
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-0033
Mailing Address - Country:US
Mailing Address - Phone:703-964-8199
Mailing Address - Fax:703-649-6188
Practice Address - Street 1:1451 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-3876
Practice Address - Country:US
Practice Address - Phone:262-547-2123
Practice Address - Fax:262-547-6204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-03
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty