Provider Demographics
NPI:1598779589
Name:CHESAPEAKE CARDIOLOGY CLINIC, P.A.
Entity Type:Organization
Organization Name:CHESAPEAKE CARDIOLOGY CLINIC, P.A.
Other - Org Name:CHESAPEAKE CARDIOLOGY CLINIC, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:410-822-5571
Mailing Address - Street 1:522 IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3824
Mailing Address - Country:US
Mailing Address - Phone:410-822-5571
Mailing Address - Fax:410-822-3859
Practice Address - Street 1:522 IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3824
Practice Address - Country:US
Practice Address - Phone:410-822-5571
Practice Address - Fax:410-822-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK375Medicare PIN