1831493030 NPI number — EVIDENCE PHYSICAL THERAPY, LLC

Table of content: (NPI 1831493030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831493030 NPI number — EVIDENCE PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVIDENCE PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVIDENCEPT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831493030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12150 ANNAPOLIS RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
GLENN DALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20769-9183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-352-8370
Provider Business Mailing Address Fax Number:
301-352-8372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12150 ANNAPOLIS RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENN DALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-352-8370
Provider Business Practice Location Address Fax Number:
301-352-8372
Provider Enumeration Date:
01/03/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOSES
Authorized Official First Name:
HASSANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
301-352-8370

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  21846 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 616235300 . This is a "WORKERS COMPENSATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 045308100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".