Basic Information
| Provider Information | |||||||||
| NPI: | 1013987312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHASE | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1412 | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064596060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 WILSON STREET | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062332600 | ||||||||
| FaxNumber: | 4062332611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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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 | 363AM0700X | PA-577 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 469 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 9970976 | 05 | MT | MEDICAID |