Provider Demographics
NPI:1588632806
Name:CHRISCO, PETER AUSTIN (PT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:AUSTIN
Last Name:CHRISCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 RIDGE GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4523
Mailing Address - Country:US
Mailing Address - Phone:812-431-7083
Mailing Address - Fax:
Practice Address - Street 1:4700 NELSON BROGDON BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5400
Practice Address - Country:US
Practice Address - Phone:770-271-3188
Practice Address - Fax:770-271-3288
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011972225100000X
GAPT0103252251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL900068033OtherTAX-ID#
ILK28891OtherMEDICARE #
IL08220357OtherBCBS GRP#
IL900068033OtherTAX-ID#