1811142771 NPI number — CHESAPEAKE PAIN CENTER, LLC

Table of content: (NPI 1811142771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811142771 NPI number — CHESAPEAKE PAIN CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESAPEAKE PAIN CENTER, LLC
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:
1811142771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 404
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEL AIR
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21014-0404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-484-2828
Provider Business Mailing Address Fax Number:
443-484-2831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2012 SOUTH TOLLGATE ROAD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BEL AIR
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21015-5901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-484-2828
Provider Business Practice Location Address Fax Number:
443-484-2831
Provider Enumeration Date:
11/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
443-484-2828

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  W11478880 , 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: 109766 . This is a "JOHNS HOPKINS HEALTH CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 5571764 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 003003100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 541744325 . This is a "COVENTRY" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 541744325 . This is a "TRICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K8170001 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 220CCH . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 10229730 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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