Provider Demographics
NPI:1154628188
Name:CHESTER RIVER HEALTH LAB - CENTREVILLE
Entity Type:Organization
Organization Name:CHESTER RIVER HEALTH LAB - CENTREVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PATIENT FINANCIAL SERVICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARDELLA
Authorized Official - Middle Name:TRYTHALL
Authorized Official - Last Name:FORRESTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPAM, CHAM
Authorized Official - Phone:410-810-5192
Mailing Address - Street 1:202 COURSEVALL DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-2804
Mailing Address - Country:US
Mailing Address - Phone:410-778-3300
Mailing Address - Fax:
Practice Address - Street 1:100 BROWN ST
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1435
Practice Address - Country:US
Practice Address - Phone:410-778-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTER RIVER HOSPITAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D022037291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000265800Medicaid
MD210030Medicare PIN