Basic Information
Provider Information | |||||||||
NPI: | 1194998484 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHESAPEAKE MEDICAL IMAGING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHESAPEAKE OPEN MRI | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 108 FORBES ST | ||||||||
Address2: |   | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214011502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102688862 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 108 FORBES ST | ||||||||
Address2: |   | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214011502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102688862 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2008 | ||||||||
LastUpdateDate: | 04/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAGANZ | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4105710350 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | LX26CH | 01 | MD | BLUE SHIELD | OTHER | F855 | 01 | DC | BLUE SHIELD | OTHER |