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9375 Chesapeake St Ste 219 La Plata MD 20646-3654 | |
| (240) 763-0843 | |
| (877) 775-0210 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 9375 Chesapeake St Ste 219, La Plata, Maryland |
| Authorized Official Name and Position | Ca'seem Tyler (CEO) |
| Authorized Official Contact | 2407630843 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
9375 Chesapeake St Ste 219 La Plata MD 20646-3654 Ph: (240) 763-0843 | 9375 Chesapeake St Ste 219 La Plata MD 20646-3654 Ph: (240) 763-0843 |
| NPI Number | 1922699198 |
|---|---|
| Provider Enumeration Date | 02/01/2021 |
| Last Update Date | 01/21/2025 |
| Certification Date | 01/21/2025 |
| Medicare PECOS PAC ID | 4587062708 |
|---|---|
| Medicare Enrollment ID | O20211001001508 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922699198 | NPI | - | NPPES |
| Provider Name | Ca'seem Tyler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912507500 PECOS PAC ID: 2365856879 Enrollment ID: I20211001001655 |
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