Provider Demographics
NPI:1295728848
Name:MARTIN - CHAFEE, EDWARD B (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:MARTIN - CHAFEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN348912080P0202X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
690476OtherFIRST HEALTH PLAN
370015977OtherRR MEDICARE
90051OtherARAZ GROUP/AMERICA'S PPO
CQ2388OtherRR MEDICARE
1207854OtherMEDICA HEALTH PLANS
074563400OtherMEDICAL ASSISTANCE (MA)
1012096OtherPREFERRED ONE
115598OtherU-CARE
4700063POtherMEDICA HEALTH PLANS
MN074563400Medicaid
HP20318OtherHEALTH PARTNERS
51G94MAOtherBLUE CROSS BLUE SHIELD
MN370001860Medicare PIN
1207854OtherMEDICA HEALTH PLANS