Provider Demographics
NPI:1629175997
Name:UPPER CHESAPEAKE SURGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:UPPER CHESAPEAKE SURGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:THOMAS AUGUSTUS
Authorized Official - Last Name:PRIOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-643-3340
Mailing Address - Street 1:421 S UNION AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3346
Mailing Address - Country:US
Mailing Address - Phone:443-843-6363
Mailing Address - Fax:443-843-6653
Practice Address - Street 1:421 S UNION AVE STE 201
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3346
Practice Address - Country:US
Practice Address - Phone:443-843-6363
Practice Address - Fax:443-843-6653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062522208600000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412489800Medicaid