Basic Information
| Provider Information | |||||||||
| NPI: | 1730431321 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC PHYSICIANS OF ANNAPOLIS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ODENTON O AND P | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 ANNAPOLIS ROAD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102958900 | ||||||||
| FaxNumber: | 4102804701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 ANNAPOLIS ROAD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102958900 | ||||||||
| FaxNumber: | 4102804701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAPUT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4102675574 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOPEDIC PHYSICIANS OF ANNAPOLIS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 449603500 | 05 | MD | MEDICAID |