Basic Information
| Provider Information | |||||||||
| NPI: | 1780123323 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESAPEAKE OPEN MRI LLC | ||||||||
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| OtherOrganizationName: | CHESAPEAKE MEDICAL IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 824106 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191824106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109310400 | ||||||||
| FaxNumber: | 4109311009 | ||||||||
| Practice Location | |||||||||
| Address1: | 5961 EXCHANGE DR | ||||||||
| Address2: | LEVEL 1 | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217849253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106441880 | ||||||||
| FaxNumber: | 4103003160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2017 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | BAGANZ | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4105710350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.