=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205948551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESAPEAKE NEUROINSTITUTE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 05/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 MEDICAL PKWY SUITE 206
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-4985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-547-9005
-----------------------------------------------------
Fax | 757-277-9939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 MEDICAL PKWY SUITE 206
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-4985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-547-9005
-----------------------------------------------------
Fax | 757-277-9939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. KARLA L HEASTIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-547-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------