Basic Information
| Provider Information | |||||||||
| NPI: | 1760693899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIPMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3988 | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629023988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 405 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6184570469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 036.133110 | IL | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 204D00000X | 005202 | AZ | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207P00000X | 005202 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2246 | ME | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036133110 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | R1028 | AZ | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 036.133110 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005202 | 01 | AZ | MEDICAL LICENSE | OTHER | 1760693899 | 05 | ME | MEDICAID |