Provider Demographics
NPI:1073784005
Name:CHESAPEAKE OPEN MRI L L C
Entity type:Organization
Organization Name:CHESAPEAKE OPEN MRI L L C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAGANZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-810-0032
Mailing Address - Street 1:122 DEFENSE HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7044
Mailing Address - Country:US
Mailing Address - Phone:302-526-1604
Mailing Address - Fax:
Practice Address - Street 1:6602 CHURCH HILL RD STE 150
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-2316
Practice Address - Country:US
Practice Address - Phone:410-810-0032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESAPEAKE OPEN MRI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-18
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408127700Medicaid
DCF855OtherBLUE SHIELD
MDLX26CHOtherBLUE SHIELD