Provider Demographics
NPI:1467513978
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:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-381-7000
Mailing Address - Street 1:314 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4823
Mailing Address - Country:US
Mailing Address - Phone:301-498-2212
Mailing Address - Fax:301-498-2213
Practice Address - Street 1:7080 DEEPAGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5219
Practice Address - Country:US
Practice Address - Phone:410-381-7000
Practice Address - Fax:410-381-3779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19690225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBX3OtherBLUE CROSS BLUE SHIELD
MDS429OtherBLUE CROSS BLUE SHIELD
MD=========OtherAETNA
MDKBX3OtherBLUE CROSS BLUE SHIELD
MDS429OtherBLUE CROSS BLUE SHIELD