Basic Information
| Provider Information | |||||||||
| NPI: | 1043805930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESTNUT MEDICINE OF WI LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33 | ||||||||
| Address2: | |||||||||
| City: | BEDFORD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604990033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039648199 | ||||||||
| FaxNumber: | 7036496188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531863876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625472123 | ||||||||
| FaxNumber: | 2625476204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2021 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | SIRAJ | ||||||||
| AuthorizedOfficialFirstName: | OMAIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7039648199 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.