Basic Information
Provider Information | |||||||||
NPI: | 1679528038 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHESAPEAKE NEUROLOGY SERVICES, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1602 NEWPORT GAP PIKE | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 198086208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026335840 | ||||||||
FaxNumber: | 3026335844 | ||||||||
Practice Location | |||||||||
Address1: | 111 W HIGH ST | ||||||||
Address2: | SUITE 107 | ||||||||
City: | ELKTON | ||||||||
State: | MD | ||||||||
PostalCode: | 219215529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103927044 | ||||||||
FaxNumber: | 4106200055 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 07/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MELNICK | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 4103927044 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 07/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 1000021421 | 05 | DE |   | MEDICAID | # 1M53CH | 01 | MD | CAREFIRST GROUP NUMBER | OTHER | DA4922 | 01 | MD | MEDICARE RR | OTHER | 406618900 | 05 | MD |   | MEDICAID |