Basic Information
| Provider Information | |||||||||
| NPI: | 1669443552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHALDECOTT | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 FORT ST | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481832040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Practice Location | |||||||||
| Address1: | 2070 BIDDLE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342259100 | ||||||||
| FaxNumber: | 7342259100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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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 | 207XS0114X | 4301061724 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XX0801X | 4301061724 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XS0117X | 4301061724 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 1699102244 | 01 | MI | GROUP NPI HENRY FORD WYANDOTTE | OTHER | 0H28427 | 01 | MI | BLUE CROSS | OTHER | 104481368 | 05 | MI | MEDICAID |