Provider Demographics
NPI:1265529465
Name:CHESAPEAKE SPINE, LLC
Entity type:Organization
Organization Name:CHESAPEAKE SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-368-8323
Mailing Address - Street 1:10705 CHARTER DR STE 430
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2870
Mailing Address - Country:US
Mailing Address - Phone:410-368-8323
Mailing Address - Fax:410-368-8324
Practice Address - Street 1:10705 CHARTER DR STE 430
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2870
Practice Address - Country:US
Practice Address - Phone:410-368-8323
Practice Address - Fax:410-368-8324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD229961500Medicaid
MDE49243Medicare UPIN