Provider Demographics
NPI:1174510879
Name:ENICH, CHAD P (PA C)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:P
Last Name:ENICH
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 86TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4201
Mailing Address - Country:US
Mailing Address - Phone:515-276-3406
Mailing Address - Fax:515-276-5141
Practice Address - Street 1:2901 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4201
Practice Address - Country:US
Practice Address - Phone:515-276-3406
Practice Address - Fax:515-276-5141
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001165146N00000X, 363A00000X
IA01165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1174510879Medicaid
44593OtherBCBS
IAP01396066OtherRR MEDICARE
IA970009403OtherRAILROAD MEDICARE
IA2133348Medicaid
IA2133348Medicaid
S67264Medicare UPIN
IA47246Medicare PIN
IA47247Medicare PIN