Provider Demographics
NPI:1588770465
Name:ANTIETAM SURGEONS CHARLES R CHANEY MD PA
Entity type:Organization
Organization Name:ANTIETAM SURGEONS CHARLES R CHANEY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ANTIETAM SURGEONS
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-791-4866
Mailing Address - Street 1:363 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5747
Mailing Address - Country:US
Mailing Address - Phone:301-791-4866
Mailing Address - Fax:301-791-1297
Practice Address - Street 1:363 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5747
Practice Address - Country:US
Practice Address - Phone:301-791-4866
Practice Address - Fax:301-791-1297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014398208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD213667OtherMDIPA
MDK4820001OtherBLUECHOICE
MD1388590OtherCIGNA
MD1388590OtherCIGNA
D70339Medicare UPIN