Basic Information
Provider Information | |||||||||
NPI: | 1033294285 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHEN | ||||||||
FirstName: | CHI | ||||||||
MiddleName: | DAI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1040 MARLBORO WAY | ||||||||
Address2: | SUITE 7 | ||||||||
City: | BENNETTSVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 295122494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8434795858 | ||||||||
FaxNumber: | 8434541092 | ||||||||
Practice Location | |||||||||
Address1: | 1040 MARLBORO WAY | ||||||||
Address2: | SUITE 7 | ||||||||
City: | BENNETTSVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 295122494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8434795858 | ||||||||
FaxNumber: | 8434541092 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2006 | ||||||||
LastUpdateDate: | 09/17/2012 | ||||||||
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 | 208600000X | 22377 | SC | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 223779 | 05 | SC |   | MEDICAID | 000000196767 | 01 | SC | UNISON | OTHER | 7162826 | 01 | SC | AETNA | OTHER | 407687 | 01 | SC | WELLCARE | OTHER |