Provider Demographics
NPI:1609989730
Name:CHESAPEAKE PRIMARY CARE GROUP PA
Entity Type:Organization
Organization Name:CHESAPEAKE PRIMARY CARE GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRADEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:GARG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-360-2400
Mailing Address - Street 1:14650 VIBURNUM DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MD
Mailing Address - Zip Code:21036-1246
Mailing Address - Country:US
Mailing Address - Phone:410-360-2400
Mailing Address - Fax:410-439-3342
Practice Address - Street 1:4304 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-4520
Practice Address - Country:US
Practice Address - Phone:410-360-2400
Practice Address - Fax:410-439-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31322207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD423LMedicare PIN