Provider Demographics
NPI:1194723353
Name:CIARDIELLO, CHRISTOPHER KENNETH (PAC)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:KENNETH
Last Name:CIARDIELLO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 BERWYN HOUSE RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2474
Mailing Address - Country:US
Mailing Address - Phone:301-220-0150
Mailing Address - Fax:301-220-1032
Practice Address - Street 1:DRY RUN ROAD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-264-1000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV643207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550738254033OtherBCBSMT STATE
WV550738254033OtherBCBSMT STATE
S65088Medicare UPIN