=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700194206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERGENCY MEDICINE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2010
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 EAST CHARLES ST. CIVISTA MEDICAL CENTER
-----------------------------------------------------
City | LA PLATA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-609-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20010 CENTURY BLVD., SUITE 200 EMERGENCY MEDICINE ASSOCIATES
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-686-2300
-----------------------------------------------------
Fax | 240-686-2330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT
-----------------------------------------------------
Name | JENNIFFER CHASTAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------