Provider Demographics
NPI:1528064045
Name:CHESAPEAKE DIAGNOSTIC LABORATORY, INC.
Entity type:Organization
Organization Name:CHESAPEAKE DIAGNOSTIC LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-560-5800
Mailing Address - Street 1:110 OLD PADONIA RD
Mailing Address - Street 2:STE 301
Mailing Address - City:COCKEYSVILLE HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-4948
Mailing Address - Country:US
Mailing Address - Phone:410-560-5800
Mailing Address - Fax:
Practice Address - Street 1:110 OLD PADONIA RD
Practice Address - Street 2:STE 301
Practice Address - City:COCKEYSVILLE HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-4948
Practice Address - Country:US
Practice Address - Phone:410-560-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD027547D291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21D0704925OtherCLIA #
MD800160000Medicaid
MD800160000Medicaid
MD00607Medicare UPIN