Provider Demographics
NPI:1275772154
Name:CHRISTOPHER CHALK, S.C.
Entity Type:Organization
Organization Name:CHRISTOPHER CHALK, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CHALK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-986-4411
Mailing Address - Street 1:1820 WINDSOR RD
Mailing Address - Street 2:STE.A
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4271
Mailing Address - Country:US
Mailing Address - Phone:815-986-4411
Mailing Address - Fax:
Practice Address - Street 1:1820 WINDSOR RD
Practice Address - Street 2:STE.A
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4271
Practice Address - Country:US
Practice Address - Phone:815-986-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006422111NS0005X, 261Q00000X
IL036097622208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1592Medicare PIN
ILU47043Medicare UPIN