Provider Demographics
NPI:1013987312
Name:CHASE, THEODORE J (PA)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:CHASE
Suffix:
Gender:M
Credentials:PA
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 1412
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301
Mailing Address - Country:US
Mailing Address - Phone:406-459-6060
Mailing Address - Fax:
Practice Address - Street 1:2600 WILSON STREET
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301
Practice Address - Country:US
Practice Address - Phone:406-233-2600
Practice Address - Fax:406-233-2611
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-577363AM0700X
MT469363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT9970976Medicaid
MT9970976Medicaid