1902093701 NPI number — JEFFREY K CHAULK MD PC

Table of content: (NPI 1902093701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902093701 NPI number — JEFFREY K CHAULK MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY K CHAULK MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902093701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1665
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAYLORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49734-5665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-732-6455
Provider Business Mailing Address Fax Number:
989-732-1102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CHEBOYGAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49721-2290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-627-3169
Provider Business Practice Location Address Fax Number:
231-627-3099
Provider Enumeration Date:
09/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHAULK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-732-6455

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901004074 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4901003939 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 4301405077 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , with the licence number: 4301081575 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3038290 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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