Provider Demographics
NPI:1720197924
Name:CHESAPEAKE NEUROSURGERY, LLC
Entity Type:Organization
Organization Name:CHESAPEAKE NEUROSURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-486-0090
Mailing Address - Street 1:2700 QUARRY LAKE DRIVE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209
Mailing Address - Country:US
Mailing Address - Phone:410-486-0090
Mailing Address - Fax:410-486-0093
Practice Address - Street 1:2700 QUARRY LAKE DRIVE
Practice Address - Street 2:SUITE 360
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209
Practice Address - Country:US
Practice Address - Phone:410-486-0090
Practice Address - Fax:410-486-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047743207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407922100Medicaid
MD880MMedicare PIN