1013106541 NPI number — CHESAPEAKE BAY ENT PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013106541 NPI number — CHESAPEAKE BAY ENT PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESAPEAKE BAY ENT PC
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:
6
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:
1013106541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1270 DIAMOND SPRINGS RD
Provider Second Line Business Mailing Address:
SUITE 118, #712
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23455-3729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-442-7040
Provider Business Mailing Address Fax Number:
757-442-7080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36080 LANKFORD HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLE HAVEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23306-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-442-7040
Provider Business Practice Location Address Fax Number:
757-442-7080
Provider Enumeration Date:
10/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAFFOLD
Authorized Official First Name:
DETRA
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
REGIONAL PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
757-442-7040

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006502903 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4102118 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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