Provider Demographics
NPI:1235117417
Name:CHESTER CLINIC PROFESSIONAL CORP
Entity Type:Organization
Organization Name:CHESTER CLINIC PROFESSIONAL CORP
Other - Org Name:STEELEVILLE FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR / CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-826-2388
Mailing Address - Street 1:2319 OLD PLANK RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233
Mailing Address - Country:US
Mailing Address - Phone:618-826-2388
Mailing Address - Fax:618-826-3350
Practice Address - Street 1:2319 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233
Practice Address - Country:US
Practice Address - Phone:618-826-2388
Practice Address - Fax:618-826-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
261Q00000X
IL060002310261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
962310Medicare ID - Type Unspecified
IL783809Medicare Oscar/Certification