Provider Demographics
NPI:1194001719
Name:CHESAPEAKE PHYSICAL AQUATIC THERAPY INC
Entity Type:Organization
Organization Name:CHESAPEAKE PHYSICAL AQUATIC THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:410-381-7000
Mailing Address - Street 1:PO BOX 21277
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-0777
Mailing Address - Country:US
Mailing Address - Phone:410-719-8661
Mailing Address - Fax:410-719-8996
Practice Address - Street 1:6785 BUSINESS PKWY
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6353
Practice Address - Country:US
Practice Address - Phone:410-579-8999
Practice Address - Fax:410-782-4308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD729MMedicare PIN