1124013586 NPI number — DR. JOHN H CHIDESTER MD

Table of content: DR. JOHN H CHIDESTER MD (NPI 1124013586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124013586 NPI number — DR. JOHN H CHIDESTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHIDESTER
Provider First Name:
JOHN
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124013586
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
254 W. LANCASTER AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MALVERN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19355-3087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-644-5040
Provider Business Mailing Address Fax Number:
610-640-9170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
254 W. LANCASTER AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MALVERN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19355-3087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-644-5040
Provider Business Practice Location Address Fax Number:
610-640-9170
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD-019797-E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3646 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 055590 . This is a "PERSONAL CHOICE PROVIDER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02598600 . This is a "IDENPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1754466 . This is a "HIGHMARK GROUP ID #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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