1073630158 NPI number — CHESTERTOWN FAMILY MEDICINE PA

Table of content: (NPI 1073630158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073630158 NPI number — CHESTERTOWN FAMILY MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESTERTOWN FAMILY MEDICINE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073630158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6602 CHURCH HILL RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHESTERTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21620-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-778-0300
Provider Business Mailing Address Fax Number:
410-778-0351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6602 CHURCH HILL RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHESTERTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21620-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-778-0300
Provider Business Practice Location Address Fax Number:
410-778-0351
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENJAMIN
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-778-0300

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D16488 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 033141400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com