Healthcare Provider Details

I. General information

NPI: 1700100583
Provider Name (Legal Business Name): CHESAPEAKE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18682 NORTHUMBERLAND HWY
REEDVILLE VA
22539-3411
US

IV. Provider business mailing address

PO BOX 1328
KILMARNOCK VA
22482-1328
US

V. Phone/Fax

Practice location:
  • Phone: 804-453-4537
  • Fax: 804-453-4317
Mailing address:
  • Phone: 804-435-8664
  • Fax: 804-435-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101028388
License Number StateVA

VIII. Authorized Official

Name: MRS. CAMILLE PERGOLA
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 804-435-8570