Healthcare Provider Details

I. General information

NPI: 1487677100
Provider Name (Legal Business Name): CARMEN D. CHASE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W VIRGINIA AVE
NORMAL IL
61761-3666
US

IV. Provider business mailing address

PO BOX 2451
BLOOMINGTON IL
61702-2451
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-2910
  • Fax: 309-268-2913
Mailing address:
  • Phone: 309-268-2172
  • Fax: 309-268-3642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: