Provider Demographics
NPI:1518247378
Name:CHESTER RIVER HEALTH LAB
Entity Type:Organization
Organization Name:CHESTER RIVER HEALTH LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PATIENT FINANCIAL SERVICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARDELLA
Authorized Official - Middle Name:TRYTHALL
Authorized Official - Last Name:FORRESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-810-5192
Mailing Address - Street 1:119C N MAIN ST
Mailing Address - Street 2:DOGWOOD PLAZA
Mailing Address - City:GALENA
Mailing Address - State:MD
Mailing Address - Zip Code:21635-1555
Mailing Address - Country:US
Mailing Address - Phone:410-648-6100
Mailing Address - Fax:
Practice Address - Street 1:119C N MAIN ST
Practice Address - Street 2:DOGWOOD PLAZA
Practice Address - City:GALENA
Practice Address - State:MD
Practice Address - Zip Code:21635-1555
Practice Address - Country:US
Practice Address - Phone:410-648-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTERRIVER HOSPITAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D022037291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000265800Medicaid
MD210030Medicare PIN