Basic Information
| Provider Information | |||||||||
| NPI: | 1831117852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRICE | ||||||||
| FirstName: | CHESTON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 S TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549826922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549826922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
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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 | 207Q00000X | 40913 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32554900 | 05 | WI | MEDICAID |