Basic Information
| Provider Information | |||||||||
| NPI: | 1902494024 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESAPEAKE WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 669 | ||||||||
| Address2: | |||||||||
| City: | CECILTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219130669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102758156 | ||||||||
| FaxNumber: | 8774336830 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219215906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102758156 | ||||||||
| FaxNumber: | 8774336830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | HYSKELL | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 8149388263 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESAPEAKE WELLNESS CENTER | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205409400 | 05 | MD | MEDICAID |