Provider Demographics
NPI:1366834749
Name:CHESAPEAKE BAY ENT
Entity Type:Organization
Organization Name:CHESAPEAKE BAY ENT
Other - Org Name:COASTAL PLAIN ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DETRA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SAFFOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-821-2090
Mailing Address - Street 1:PO BOX 68279
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-8279
Mailing Address - Country:US
Mailing Address - Phone:757-821-2090
Mailing Address - Fax:757-821-2091
Practice Address - Street 1:1232 PERIMETER PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5924
Practice Address - Country:US
Practice Address - Phone:757-821-2090
Practice Address - Fax:757-821-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689693939OtherNPI