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General NPI Number Information
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NPI Number | 1932115771
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Entity Type | Individual
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Provider Name | CHAD BLAISE KRILICH M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 05/11/2023
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Provider Practice Location Address
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Address Line | 401 BICENTENNIAL WAY
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City | SANTA ROSA
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State | CA
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Zip | 95403-2149
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Country | US
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Telephone | 253-677-1625
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Fax |
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Provider Business Mailing Address
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Address Line | 5656 EASTLAKE DR
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City | SANTA ROSA
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State | CA
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Zip | 95409-3075
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Country | US
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Telephone | 253-677-1625
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD00042765
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License Number State | WA
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