1295802593 NPI number — PLAZA REHABILITATION, LLC

Table of content: (NPI 1295802593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295802593 NPI number — PLAZA REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLAZA REHABILITATION, 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:
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:
1295802593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1912 LIBERTY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21784-6602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-795-7696
Provider Business Mailing Address Fax Number:
410-795-5789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1912 LIBERTY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYKESVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21784-6602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-795-7696
Provider Business Practice Location Address Fax Number:
410-795-5789
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LYONS
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-795-7696

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  17195 , 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)

  • Identifier: 3584115 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3584226 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7295156 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2126696 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 962APL . This is a "CAREFIRST MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: T473 . This is a "GHMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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