Basic Information
Provider Information | |||||||||
NPI: | 1932480589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SPELL | ||||||||
FirstName: | CHASE | ||||||||
MiddleName: | BENJAMIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 907 18TH ST E | ||||||||
Address2: | SUITE 150 | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317943643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293865222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1610 JOHN ORR DR | ||||||||
Address2: |   | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317943682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293865222 | ||||||||
FaxNumber: | 2293862025 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2011 | ||||||||
LastUpdateDate: | 06/18/2015 | ||||||||
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 | 363AS0400X | 2154 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.