Provider Demographics
NPI:1164751251
Name:CHESAPEAKE LASER & SKIN CARE
Entity Type:Organization
Organization Name:CHESAPEAKE LASER & SKIN CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:PEITHMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA C
Authorized Official - Phone:410-530-0331
Mailing Address - Street 1:127 TANNERS POINT DR
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-3701
Mailing Address - Country:US
Mailing Address - Phone:407-328-0825
Mailing Address - Fax:407-322-5478
Practice Address - Street 1:127 TANNERS POINT DR
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666-3701
Practice Address - Country:US
Practice Address - Phone:407-328-0825
Practice Address - Fax:407-322-5478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001172363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty