Basic Information
| Provider Information | |||||||||
| NPI: | 1225036007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHASE | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609278105 | ||||||||
| FaxNumber: | 2609278026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 E 7TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609250403 | ||||||||
| FaxNumber: | 2609259545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01034432 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100104000 | 05 | IN | MEDICAID |