Basic Information
| Provider Information | |||||||||
| NPI: | 1275687535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESAPEAKE PHYSICAL & AQUATIC THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13946 BALTIMORE AVE. | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014982212 | ||||||||
| FaxNumber: | 3014982213 | ||||||||
| Practice Location | |||||||||
| Address1: | 13946 BALTIMORE AVE | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207075000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014982212 | ||||||||
| FaxNumber: | 3014982213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
| AuthorizedOfficialFirstName: | JARED | ||||||||
| AuthorizedOfficialMiddleName: | STEWART | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4103817000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | KBX3 | 01 | MD | BLUE CROSS MD PROVIDER # | OTHER | S429 | 01 | MD | BLUE CROSS DC PROVIDER # | OTHER |