Basic Information
| Provider Information | |||||||||
| NPI: | 1912458381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHASE BREXTON HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHASE BREXTON GLEN BURNIE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HOSPITAL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108372050 | ||||||||
| FaxNumber: | 4435735010 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HOSPITAL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108372050 | ||||||||
| FaxNumber: | 4435735010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2016 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUMMERFIELD | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AVP - PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 4108372050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | 07421 | MD | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 507702800 | 05 | MD | MEDICAID | 2165831 | 01 | PK | OTHER |