Provider Demographics
NPI:1497710339
Name:CHESAPEAKE PODIATRY GROUP PA
Entity Type:Organization
Organization Name:CHESAPEAKE PODIATRY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-363-2233
Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:STE 410
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:410-363-2233
Mailing Address - Fax:410-363-2235
Practice Address - Street 1:910 WASHINGTON RD
Practice Address - Street 2:STE D
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157
Practice Address - Country:US
Practice Address - Phone:410-876-8637
Practice Address - Fax:410-857-5273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00898335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0974120002Medicare NSC