Provider Demographics
NPI:1104459502
Name:CHEVY CHASE PRIMARY CARE LLC
Entity type:Organization
Organization Name:CHEVY CHASE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-269-7337
Mailing Address - Street 1:330 ROMANY RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2404
Mailing Address - Country:US
Mailing Address - Phone:859-269-7337
Mailing Address - Fax:859-335-0157
Practice Address - Street 1:330 ROMANY RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2404
Practice Address - Country:US
Practice Address - Phone:859-269-7337
Practice Address - Fax:859-335-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1669453635OtherNPI
KY1063981231OtherNPI