1124230966 NPI number — SPORT & SPINE REHAB OF COLUMBIA

Table of content: (NPI 1124230966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124230966 NPI number — SPORT & SPINE REHAB OF COLUMBIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORT & SPINE REHAB OF COLUMBIA
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:
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:
1124230966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11418 LIVINGSTON ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT. WASHINGTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-964-0837
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10760 HICKORY RIDGE ROAD
Provider Second Line Business Practice Location Address:
119
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-964-0837
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREENSTEIN
Authorized Official First Name:
JAY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
410-964-0837

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2103322 . This is a "OPTIMUM CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4535854 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: G921 . This is a "BCBS OF NCA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3348462 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200064 . This is a "CIGNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200289 . This is a "ASHN CIGNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2103322 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2103322 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2103322 . This is a "MDIPA" identifier . This identifiers is of the category "OTHER".
  • Identifier: KEG7SP . This is a "BCBS OF MD" identifier . This identifiers is of the category "OTHER".




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