Healthcare Provider Details

I. General information

NPI: 1396934816
Provider Name (Legal Business Name): CHESAPEAKE PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 OLD SOLOMONS ISLAND RD
ANNAPOLIS MD
21401
US

IV. Provider business mailing address

121 OLD SOLOMONS ISLAND RD
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-3663
  • Fax: 410-224-2693
Mailing address:
  • Phone: 410-224-3663
  • Fax: 410-224-2693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD12796
License Number StateMD

VIII. Authorized Official

Name: KENNETH M HOFFMAN
Title or Position: ADMINISTRATIVE OFFICIAL
Credential: MD
Phone: 410-224-3633