Healthcare Provider Details

I. General information

NPI: 1437245859
Provider Name (Legal Business Name): PENINSULA GASTROENTEROLOGY ASSN , P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 OCEAN HWY SUITE B
DELMAR MD
21875-2339
US

IV. Provider business mailing address

PO BOX 157
DELMAR DE
19940-0157
US

V. Phone/Fax

Practice location:
  • Phone: 410-896-3693
  • Fax: 410-896-3698
Mailing address:
  • Phone: 410-896-3693
  • Fax: 410-896-3698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: KOTA CHANDRASEKHARA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-896-3693