Provider Demographics
NPI:1356454706
Name:CHESTER FAMILY PRACTICE
Entity Type:Organization
Organization Name:CHESTER FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MUDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-872-0565
Mailing Address - Street 1:521 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-6136
Mailing Address - Country:US
Mailing Address - Phone:610-872-0565
Mailing Address - Fax:610-872-4478
Practice Address - Street 1:521 E 9TH ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-6136
Practice Address - Country:US
Practice Address - Phone:610-872-0565
Practice Address - Fax:610-872-4478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029229E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0554265001Medicaid
PA5023294OtherBLUE SHIELD
PAB41974Medicare UPIN
PA717563Medicare PIN