Provider Demographics
NPI:1215065727
Name:JEFFREY K CHAULK MD PC
Entity type:Organization
Organization Name:JEFFREY K CHAULK MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHAULK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-732-6455
Mailing Address - Street 1:PO BOX 1665
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49734-5665
Mailing Address - Country:US
Mailing Address - Phone:989-732-6455
Mailing Address - Fax:989-732-1102
Practice Address - Street 1:350 W NORTH ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1525
Practice Address - Country:US
Practice Address - Phone:989-732-6455
Practice Address - Fax:989-732-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004074152W00000X
MI4901003939152W00000X
MI4301405077207W00000X
MI5101016992207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180F910770OtherBCBS OD
MI1806920011OtherBLUE CARE NETWORK
MI3038315Medicaid
MI180F910760OtherBCBS MD
MICJ0562OtherRAILROAD MEDICARE
MI900F910770OtherBLUE CARE NETWORK
MI900F910770OtherBCBS
MI1806920011OtherBCBS
MI180F910770OtherBCBS OD
MIB46881Medicare UPIN
MI1806920011OtherBLUE CARE NETWORK