Healthcare Provider Details

I. General information

NPI: 1447714829
Provider Name (Legal Business Name): CHESAPEAKE PLASTIC SURGERY SUITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8028 RITCHIE HWY STE 100
PASADENA MD
21122-1020
US

IV. Provider business mailing address

8028 RITCHIE HWY STE 100
PASADENA MD
21122-1020
US

V. Phone/Fax

Practice location:
  • Phone: 443-695-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IRA GOTTLIEB
Title or Position: OWNER
Credential: DPM
Phone: 443-695-4500