Basic Information
| Provider Information | |||||||||
| NPI: | 1427119700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHESTANG | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 12366 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352022366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057807101 | ||||||||
| FaxNumber: | 2052068338 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 PRINCETON AVE SW | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052068461 | ||||||||
| FaxNumber: | 2052068484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 21119 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 515-39989 | 01 | AL | BCBS | OTHER | G91272 | 01 | AL | VIVA | OTHER | G91272 | 01 | AL | HEALTHSPRING | OTHER | G91272 | 01 | AL | UNITED HEALTHCARE | OTHER | 009942582 | 05 | AL | MEDICAID |