1558323543 NPI number — DR. TEMUJIN TOM CHAVEZ M.D.

Table of content: DR. TEMUJIN TOM CHAVEZ M.D. (NPI 1558323543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558323543 NPI number — DR. TEMUJIN TOM CHAVEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAVEZ
Provider First Name:
TEMUJIN
Provider Middle Name:
TOM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558323543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11271
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 PAMPLICO HWY
Provider Second Line Business Practice Location Address:
SUITE B-125
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29505-6047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-674-6400
Provider Business Practice Location Address Fax Number:
843-674-6410
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171000000X , with the licence number:  0101235352 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: TL34011 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 340116 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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