Basic Information
| Provider Information | |||||||||
| NPI: | 1578531356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESAPEAKE REHAB EQUIPMENT INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NUMOTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2070 LITTLE HILLS EXPY | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633013708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144477500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 LORD BALTIMORE DR | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212442648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102984555 | ||||||||
| FaxNumber: | 4102983239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING AND LICENSURE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3144477515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESAPEAKE REHAB EQUIPMENT INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | R965 | MD | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 1007514300007 | 05 | PA | MEDICAID | 009130039 | 05 | VA | MEDICAID | 233878500 | 05 | MD | MEDICAID | 024934500 | 05 | DC | MEDICAID |