Provider Demographics
NPI:1518931245
Name:CHILLAG, KIPP L (DO)
Entity Type:Individual
Prefix:
First Name:KIPP
Middle Name:L
Last Name:CHILLAG
Suffix:
Gender:M
Credentials:DO
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 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-672-4243
Mailing Address - Fax:231-727-4214
Practice Address - Street 1:1675 LEAHY ST STE 401A
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5547
Practice Address - Country:US
Practice Address - Phone:231-672-4243
Practice Address - Fax:231-727-4214
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI510101140172080P0008X
MI51010140172084N0402X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400493386OtherMEDICARE PTAN
MI0M74460035OtherMEDICARE ID