Basic Information
| Provider Information | |||||||||
| NPI: | 1760477582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAFIN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | BRETT | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CHAFIN | ||||||||
| OtherFirstName: | J | ||||||||
| OtherMiddleName: | BRETT | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 CHILDRENS WAY | ||||||||
| Address2: | NEMOURS CHILDRENS CLINIC, JACKSONVILLE | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046973694 | ||||||||
| FaxNumber: | 9046973927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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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 | 207Y00000X | 18351 | WV | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 33730 | KY | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | ME108101 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 040010292 | 01 | WV | RR MEDICARE | OTHER | 040011865 | 01 | KY | RR MEDICARE | OTHER | 0100892000 | 05 | WV | MEDICAID | 64941669 | 05 | KY | MEDICAID |