Provider Demographics
NPI:1902093701
Name:JEFFREY K CHAULK MD PC
Entity Type:Organization
Organization Name:JEFFREY K CHAULK MD PC
Other - Org Name:ALPINE EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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 1:810 S MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2290
Practice Address - Country:US
Practice Address - Phone:231-627-3169
Practice Address - Fax:231-627-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004074152W00000X
MI4901003939152W00000X
MI4301405077207W00000X
MI4301081575207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3038290Medicaid
0585020003Medicare NSC
MI0F94502Medicare PIN
MI3038290Medicaid