Provider Demographics
NPI:1700100583
Name:CHESAPEAKE MEDICAL GROUP
Entity Type:Organization
Organization Name:CHESAPEAKE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERGOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-435-8570
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1328
Mailing Address - Country:US
Mailing Address - Phone:804-435-8664
Mailing Address - Fax:804-435-8037
Practice Address - Street 1:18682 NORTHUMBERLAND HWY
Practice Address - Street 2:
Practice Address - City:REEDVILLE
Practice Address - State:VA
Practice Address - Zip Code:22539-3411
Practice Address - Country:US
Practice Address - Phone:804-453-4537
Practice Address - Fax:804-453-4317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA101135Medicare PIN