MEDICARE: ILENE CHAZAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT19701	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y006X	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1396817946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILENE CHAZAN

Provider Business Mailing Address
First Line	:	3576 SAINT JOHNS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-8446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3576 SAINT JOHNS AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-8446
Country	:	US
Telephone Number	:	904-421-2119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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Directions to “ ILENE CHAZAN ” Practice Location

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