Basic Information
| Provider Information | |||||||||
| NPI: | 1659620672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCOLLUM | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2323 W ROSE GARDEN LN | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850272530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239317999 | ||||||||
| FaxNumber: | 6238425640 | ||||||||
| Practice Location | |||||||||
| Address1: | 5605 W EUGIE AVE STE 110 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853041273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238472000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 03/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5259 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 5259 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 2085R0202X | 5259 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 744737 | 05 | AZ | MEDICAID |