Provider Demographics
NPI:1407920143
Name:CHESAPEAKE ORTHOPAEDIC AND SPORTS MEDICINE CENTER PA
Entity Type:Organization
Organization Name:CHESAPEAKE ORTHOPAEDIC AND SPORTS MEDICINE CENTER PA
Other - Org Name:DRS COURTNEY, KEATS & JAWORSKI PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAZMEN
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:410-768-5555
Mailing Address - Street 1:200 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-768-5555
Mailing Address - Fax:410-768-5835
Practice Address - Street 1:200 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-768-5555
Practice Address - Fax:410-768-5835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD912851400Medicaid
6048680001Medicare NSC
MD912851400Medicaid