Healthcare Provider Details

I. General information

NPI: 1013987312
Provider Name (Legal Business Name): THEODORE J CHASE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 WILSON STREET
MILES CITY MT
59301
US

IV. Provider business mailing address

PO BOX 1412
MILES CITY MT
59301
US

V. Phone/Fax

Practice location:
  • Phone: 406-233-2600
  • Fax: 406-233-2611
Mailing address:
  • Phone: 406-459-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-577
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number469
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: