1902825078 NPI number — OPTIMAL PHYSICAL THERAPY

Table of content: (NPI 1902825078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902825078 NPI number — OPTIMAL PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL PHYSICAL THERAPY
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:
1902825078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10020 SOUTHERN MARYLAND BLVD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNKIRK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20754-3036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-855-6326
Provider Business Mailing Address Fax Number:
301-855-6328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10020 SOUTHERN MARYLAND BLVD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNKIRK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20754-3036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-855-6326
Provider Business Practice Location Address Fax Number:
301-855-6328
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAMERIS
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
301-855-6326

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  19922 , 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: 743BOP . This is a "BCBS MD PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K4980001 . This is a "BCBS DC PROVIDER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3128965 . This is a "OPTIMUM CHOICE PROVIDER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 45519 . This is a "INJURED WORKERS INS FUND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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