Provider Demographics
NPI:1215044490
Name:POTTMEYER, CHRISTOPHER W (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:W
Last Name:POTTMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9040
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-9040
Mailing Address - Country:US
Mailing Address - Phone:618-462-0499
Mailing Address - Fax:618-462-1150
Practice Address - Street 1:1 SAINT ANTHONYS WAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4568
Practice Address - Country:US
Practice Address - Phone:618-465-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00449454OtherRR MEDICARE
ILC51991Medicare UPIN
K48833Medicare PIN