Basic Information
| Provider Information | |||||||||
| NPI: | 1811139900 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESAPEAKE ENT/PLASTIC FACIAL SURGERY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHESAPEAKE ENT/AUDIOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8571 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176048571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103984679 | ||||||||
| FaxNumber: | 4106203686 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W HIGH ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219215529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103986570 | ||||||||
| FaxNumber: | 4103989597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2009 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | SOKOLOWSKI | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 4103986570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCC-A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 01023 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 407609500 | 05 | MD | MEDICAID |