Provider Demographics
NPI:1285221093
Name:CHESAPEAKE WELLNESS CENTER
Entity Type:Organization
Organization Name:CHESAPEAKE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HYSKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-938-8263
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:CECILTON
Mailing Address - State:MD
Mailing Address - Zip Code:21913-0669
Mailing Address - Country:US
Mailing Address - Phone:410-275-8156
Mailing Address - Fax:877-433-6830
Practice Address - Street 1:818 HIGH ST
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1152
Practice Address - Country:US
Practice Address - Phone:410-275-8156
Practice Address - Fax:877-433-6830
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESAPEAKE WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-28
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD627009300Medicaid