Provider Demographics
NPI:1851517379
Name:CHESAPEAKE CENTER FOR COSMETIC AND PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:CHESAPEAKE CENTER FOR COSMETIC AND PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRENGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-673-5900
Mailing Address - Street 1:5818 HARBOUR VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3315
Mailing Address - Country:US
Mailing Address - Phone:757-673-5900
Mailing Address - Fax:757-673-5905
Practice Address - Street 1:5818 HARBOUR VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-673-5900
Practice Address - Fax:757-673-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041085174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6901395Medicaid
VA15906OtherOPTIMASENTARA
VA118152OtherBLUE CROSS
VAC47291Medicare UPIN
VA6901395Medicaid