1013106541 NPI number — CHESAPEAKE BAY ENT PC

Table of content: (NPI 1013106541)

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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