1760415186 NPI number — CHESAPEAKE OPEN MRI L L C

Table of content: (NPI 1760415186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760415186 NPI number — CHESAPEAKE OPEN MRI L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESAPEAKE OPEN MRI L L C
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:
1760415186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 DEFENSE HWY STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401-7044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-590-0015
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-5860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-590-0015
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAGANZ
Authorized Official First Name:
MARK
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-571-0350

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F855 . This is a "BLUE SHIELD" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: LX26CH . This is a "BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 408127700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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