Provider Demographics
NPI:1013106541
Name:CHESAPEAKE BAY ENT PC
Entity Type:Organization
Organization Name:CHESAPEAKE BAY ENT PC
Other - Org Name:COASTAL PLAIN ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DETRA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SAFFOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-442-7040
Mailing Address - Street 1:1270 DIAMOND SPRINGS RD
Mailing Address - Street 2:SUITE 118, #712
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-3729
Mailing Address - Country:US
Mailing Address - Phone:757-442-7040
Mailing Address - Fax:757-442-7080
Practice Address - Street 1:36080 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:BELLE HAVEN
Practice Address - State:VA
Practice Address - Zip Code:23306-0000
Practice Address - Country:US
Practice Address - Phone:757-442-7040
Practice Address - Fax:757-442-7080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006502903Medicaid
MD4102118 00Medicaid