1821193731 NPI number — MRS. PEGGY MICHELLE CHIDESTER MPT, CERT. MDT

Table of content: MRS. PEGGY MICHELLE CHIDESTER MPT, CERT. MDT (NPI 1821193731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821193731 NPI number — MRS. PEGGY MICHELLE CHIDESTER MPT, CERT. MDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHIDESTER
Provider First Name:
PEGGY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT, CERT. MDT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SELTZ
Provider Other First Name:
PEGGY
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821193731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4379 E GRAND RIVER AVE
Provider Second Line Business Practice Location Address:
STE 12
Provider Business Practice Location Address City Name:
HOWELL
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48843-6583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-586-0008
Provider Business Practice Location Address Fax Number:
517-586-0025
Provider Enumeration Date:
09/14/2006

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: 225100000X , with the licence number:  5501008387 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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