Basic Information
| Provider Information | |||||||||
| NPI: | 1134783079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHESSMORE | ||||||||
| FirstName: | MAURICE | ||||||||
| MiddleName: | ALLEN DALE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2448 S 3RD STREET PLZ | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681081708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086270548 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 E 20TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055751644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2019 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.