Healthcare Provider Details

I. General information

NPI: 1689985194
Provider Name (Legal Business Name): CHOPTANK COMMUNITY HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SEYMOUR AVE
ST. MICHAEL'S MD
21663-2930
US

IV. Provider business mailing address

100 SEYMOUR AVE
ST MICHAELS MD
21663-2930
US

V. Phone/Fax

Practice location:
  • Phone: 410-745-2882
  • Fax: 410-479-1714
Mailing address:
  • Phone: 410-745-2882
  • Fax: 410-479-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier784381000
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: SARA RICH
Title or Position: CEO
Credential:
Phone: 410-479-4306