Basic Information
| Provider Information | |||||||||
| NPI: | 1730233479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESAPEAKE PHYSICAL AQUATIC THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 314 MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207074823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014982212 | ||||||||
| FaxNumber: | 3014982213 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 FREDERICK RD | ||||||||
| Address2: | |||||||||
| City: | CATONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107198661 | ||||||||
| FaxNumber: | 4107198996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 12/19/2008 | ||||||||
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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 | 2251X0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | KBX3 | 01 | MD | BLUE SHIELD MD | OTHER |