Provider Demographics
NPI:1114908365
Name:CHASE, JERRY STEPHENS (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:STEPHENS
Last Name:CHASE
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 1:2300 MANCHESTER EXPY
Mailing Address - Street 2:BLD F8
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-576-5922
Mailing Address - Fax:706-327-4296
Practice Address - Street 1:2300 MANCHESTER EXPY
Practice Address - Street 2:BLD F8
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-576-5922
Practice Address - Fax:706-327-4296
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00148211CMedicaid
C72091Medicare UPIN