Provider Demographics
NPI:1629285176
Name:CHESTERFIELD PEDIATRICS
Entity Type:Organization
Organization Name:CHESTERFIELD PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:636-519-8899
Mailing Address - Street 1:16216 BAXTER ROAD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017
Mailing Address - Country:US
Mailing Address - Phone:636-519-8899
Mailing Address - Fax:636-519-0011
Practice Address - Street 1:16216 BAXTER ROAD
Practice Address - Street 2:SUITE 310
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:636-519-8899
Practice Address - Fax:636-519-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORIC342080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501104707Medicaid