Provider Demographics
NPI:1629346812
Name:CHESTER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CHESTER MEDICAL GROUP, LLC
Other - Org Name:CHESTER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-826-2388
Mailing Address - Street 1:2319 OLD PLANK RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-1153
Mailing Address - Country:US
Mailing Address - Phone:618-826-2388
Mailing Address - Fax:618-826-5798
Practice Address - Street 1:2319 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1153
Practice Address - Country:US
Practice Address - Phone:618-826-2388
Practice Address - Fax:618-826-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty