Basic Information
| Provider Information | |||||||||
| NPI: | 1740277011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHADBOURNE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 887 | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296200887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643667902 | ||||||||
| FaxNumber: | 8643666062 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W GREENWOOD ST STE 8A | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296205727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643666060 | ||||||||
| FaxNumber: | 8643666062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 81829 | SC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 10444433 | 01 | CAQH | OTHER | 818299 | 05 | SC | MEDICAID | GP4449 | 05 | SC | MEDICAID |