Healthcare Provider Details

I. General information

NPI: 1104166685
Provider Name (Legal Business Name): CHESAPEAKE OTOLARYNGOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MITCHELLVILLE RD A414
BOWIE MD
20716-3104
US

IV. Provider business mailing address

4000 MITCHELLVILLE RD A414
BOWIE MD
20716-3104
US

V. Phone/Fax

Practice location:
  • Phone: 301-860-0985
  • Fax: 301-860-0978
Mailing address:
  • Phone: 301-860-0985
  • Fax: 301-860-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number000676
License Number StateMD

VIII. Authorized Official

Name: SHELLY WALTIMYER
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-860-0985