Provider Demographics
NPI:1487677100
Name:CHASE, CARMEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:D
Last Name:CHASE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3642
Practice Address - Street 1:403 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3666
Practice Address - Country:US
Practice Address - Phone:309-268-2910
Practice Address - Fax:309-268-2913
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732028OtherBLUE CROSS BLUE SHIELD
K09718Medicare ID - Type Unspecified
05732028OtherBLUE CROSS BLUE SHIELD
IL206744Medicare ID - Type UnspecifiedMEDICARE GROUP