Provider Demographics
NPI:1053452326
Name:CHESAPEAKE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:CHESAPEAKE MEDICAL SUPPLY, INC
Other - Org Name:PHILADELPHIA REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOUSLOG
Authorized Official - Suffix:
Authorized Official - Credentials:ATP
Authorized Official - Phone:215-755-0255
Mailing Address - Street 1:937 CHESTER PIKE
Mailing Address - Street 2:4M
Mailing Address - City:PROSPECT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19076-2331
Mailing Address - Country:US
Mailing Address - Phone:215-755-0255
Mailing Address - Fax:
Practice Address - Street 1:937 CHESTER PIKE
Practice Address - Street 2:4M
Practice Address - City:PROSPECT PARK
Practice Address - State:PA
Practice Address - Zip Code:19076-2331
Practice Address - Country:US
Practice Address - Phone:215-755-0255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000004048332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012883280002Medicaid
DE0000538218Medicaid
PA0012883280002Medicaid