1518247378 NPI number — CHESTER RIVER HEALTH LAB

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 1518247378 NPI number — CHESTER RIVER HEALTH LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESTER RIVER HEALTH LAB
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:
1518247378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119C N MAIN ST
Provider Second Line Business Mailing Address:
DOGWOOD PLAZA
Provider Business Mailing Address City Name:
GALENA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21635-1555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-648-6100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119C N MAIN ST
Provider Second Line Business Practice Location Address:
DOGWOOD PLAZA
Provider Business Practice Location Address City Name:
GALENA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21635-1555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-648-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FORRESTER
Authorized Official First Name:
CARDELLA
Authorized Official Middle Name:
TRYTHALL
Authorized Official Title or Position:
DIRECTOR, PATIENT FINANCIAL SERVICE
Authorized Official Telephone Number:
410-810-5192

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  21D022037 , 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: 000265800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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