1124122296 NPI number — MR. DAVID GEORGE AMBROSE BS ATC PTA

Table of content: MR. DAVID GEORGE AMBROSE BS ATC PTA (NPI 1124122296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124122296 NPI number — MR. DAVID GEORGE AMBROSE BS ATC PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMBROSE
Provider First Name:
DAVID
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BS ATC PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1124122296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1414 RIGDON ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JARRETTSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21084-1613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-557-7590
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8322 BELLONA AVE
Provider Second Line Business Practice Location Address:
TOWSON SPORTS MEDICINE
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-337-8847
Provider Business Practice Location Address Fax Number:
410-337-5189
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  A2434 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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