Provider Demographics
NPI:1306106562
Name:CAMPBELL, CHASE (MD)
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:CAMPBELL
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:PO BOX 912688
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2688
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:719-591-2745
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:719-591-2745
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10043077207R00000X
CODR.00597072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02023278OtherRR MEDICARE
CO1306106562Medicaid
CO651158OtherMEDICARE