Provider Demographics
NPI:1821193731
Name:CHIDESTER, PEGGY MICHELLE (MPT, CERT MDT)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:MICHELLE
Last Name:CHIDESTER
Suffix:
Gender:F
Credentials:MPT, CERT MDT
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:MICHELLE
Other - Last Name:SELTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4379 E GRAND RIVER AVE
Practice Address - Street 2:STE 12
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-6583
Practice Address - Country:US
Practice Address - Phone:517-586-0008
Practice Address - Fax:517-586-0025
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750109Medicare PIN