Healthcare Provider Details

I. General information

NPI: 1902494024
Provider Name (Legal Business Name): CHESAPEAKE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E MAIN ST
ELKTON MD
21921-5906
US

IV. Provider business mailing address

PO BOX 669
CECILTON MD
21913-0669
US

V. Phone/Fax

Practice location:
  • Phone: 410-275-8156
  • Fax: 877-433-6830
Mailing address:
  • Phone: 410-275-8156
  • Fax: 877-433-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JANE E HYSKELL
Title or Position: CREDENTIALING AGENT
Credential:
Phone: 814-938-8263