Provider Demographics
NPI:1639223381
Name:CHESAPEAKE PHYSICAL AQUATIC THERAPY INC
Entity Type:Organization
Organization Name:CHESAPEAKE PHYSICAL AQUATIC THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-262-5852
Mailing Address - Street 1:314 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4823
Mailing Address - Country:US
Mailing Address - Phone:301-262-5852
Mailing Address - Fax:301-262-3173
Practice Address - Street 1:100 WHITE MARSH PARK DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4361
Practice Address - Country:US
Practice Address - Phone:301-262-5852
Practice Address - Fax:301-262-3173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCS429OtherBLUE CROSS BLUE SHIELD
MDKBX3OtherBLUE SHIELD MD PROVIDER#
DCG01032Medicare PIN
MDKBX3OtherBLUE SHIELD MD PROVIDER#