Basic Information
| Provider Information | |||||||||
| NPI: | 1194723353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIARDIELLO | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 BERWYN HOUSE RD | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207402474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012200150 | ||||||||
| FaxNumber: | 3012201032 | ||||||||
| Practice Location | |||||||||
| Address1: | DRY RUN ROAD | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042641000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 643 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 550738254033 | 01 | WV | BCBSMT STATE | OTHER |