Provider Demographics
NPI:1740555093
Name:GELDERNICK, CHRIS M (MS RD LDN)
Entity type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:M
Last Name:GELDERNICK
Suffix:
Gender:M
Credentials:MS RD LDN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1601 S 24TH ST APT 410
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-6965
Mailing Address - Country:US
Mailing Address - Phone:630-209-4390
Mailing Address - Fax:217-223-9716
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-223-9716
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005594133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00132061OtherBLUE CROSS BLUE SHIELD ILLINOIS
IL216573011Medicare PIN