Basic Information
Provider Information | |||||||||
NPI: | 1205254026 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHIMAH | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | NDIDI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 PARK CENTER CT STE 200 | ||||||||
Address2: |   | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211174221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8555277246 | ||||||||
FaxNumber: | 8662295063 | ||||||||
Practice Location | |||||||||
Address1: | 110 HOSPITAL RD STE 305 | ||||||||
Address2: |   | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8555277246 | ||||||||
FaxNumber: | 8662295063 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2014 | ||||||||
LastUpdateDate: | 04/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | D0085915 | MD | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 931092400 | 05 | MD |   | MEDICAID |