Basic Information
| Provider Information | |||||||||
| NPI: | 1588632806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISCO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | AUSTIN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3733 RIDGE GROVE WAY | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300244523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124317083 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 NELSON BROGDON BLVD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305185400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702713188 | ||||||||
| FaxNumber: | 7702713288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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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 | 225100000X | 070011972 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | PT010325 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 900068033 | 01 | IL | TAX-ID# | OTHER | K28891 | 01 | IL | MEDICARE # | OTHER | 08220357 | 01 | IL | BCBS GRP# | OTHER |