Provider Demographics
NPI:1518134402
Name:HARRISON, CHESTER EARL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:EARL
Last Name:HARRISON
Suffix:JR
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 1:2040 W ILES AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4183
Mailing Address - Country:US
Mailing Address - Phone:217-789-0668
Mailing Address - Fax:
Practice Address - Street 1:3050 MONTVALE DR STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6924
Practice Address - Country:US
Practice Address - Phone:217-726-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-11
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013944A2085R0202X
IL0361321592085R0202X
MO20130088872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036132159Medicaid