Basic Information
| Provider Information | |||||||||
| NPI: | 1114290293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESTER RIVER HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHESTERTOWN VASCULAR SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 BROWN ST | ||||||||
| Address2: | |||||||||
| City: | CHESTERTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216201435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | 4108224958 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BROWN ST | ||||||||
| Address2: | |||||||||
| City: | CHESTERTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216201435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | 4108224958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2012 | ||||||||
| LastUpdateDate: | 02/20/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4108221000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 14022 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.