MEDICARE: CHMG CORELIFE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363L00000X	Nurse Practitioner
2	104100000X	Social Worker
3	1041C0700X	Clinical Social Worker
4	133V00000X	Registered Dietitian
5	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1629660147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHMG CORELIFE, LLC

Provider Business Mailing Address
First Line	:	1099 WINTERSON RD STE 300
Second Line	:
City	:	LINTHICUM HEIGHTS
State	:	MD
Zip	:	21090-2279
Country	:	US
Telephone Number	:	800-905-3261
Fax Number	:	443-836-5606

Provider Business Practice Location Address
First Line	:	1036 SAINT NICHOLAS DR UNIT 101
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20603-4758
Country	:	US
Telephone Number	:	240-261-7170
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CAROLYN HEITHAUS
Credential	:
Telephone Number	:	410-535-8236

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	01/16/2024

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