1396640785 NPI number — PROFLEX PHYSICAL THEARPY OF MARYLAND, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396640785 NPI number — PROFLEX PHYSICAL THEARPY OF MARYLAND, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFLEX PHYSICAL THEARPY OF MARYLAND, 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:
1396640785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 791217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21279-1217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-932-4786
Provider Business Mailing Address Fax Number:
301-932-4789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 OSPREY WAY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21701-1958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-369-4461
Provider Business Practice Location Address Fax Number:
240-454-0158
Provider Enumeration Date:
10/14/2026

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JA'NISE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
301-932-4788

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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