Healthcare Provider Details

I. General information

NPI: 1053469510
Provider Name (Legal Business Name): CHESAPEAKE LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 WILKENS AVE SUITE 205
BALTIMORE MD
21229-5213
US

IV. Provider business mailing address

3455 WILKENS AVE SUITE 205
BALTIMORE MD
21229-5213
US

V. Phone/Fax

Practice location:
  • Phone: 410-242-3762
  • Fax: 410-242-3763
Mailing address:
  • Phone: 410-242-3762
  • Fax: 410-242-3763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateMD

VIII. Authorized Official

Name: SANFORD J. SIEGEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-581-1600