1043562051 NPI number — SOUTH MOUNTAIN REHABILITATION INC

Table of content: (NPI 1043562051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043562051 NPI number — SOUTH MOUNTAIN REHABILITATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH MOUNTAIN REHABILITATION INC
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:
6
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:
1043562051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9722 MOUNT TABOR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21769-9523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-818-8630
Provider Business Mailing Address Fax Number:
240-356-0340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4707 SCHLEY AVE # F
Provider Second Line Business Practice Location Address:
STE 595
Provider Business Practice Location Address City Name:
BRADDOCK HEIGHTS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21714-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-356-0330
Provider Business Practice Location Address Fax Number:
240-356-0340
Provider Enumeration Date:
10/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MCQUARRIE
Authorized Official First Name:
PENELOPE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PT, PRESIDENT
Authorized Official Telephone Number:
240-818-8630

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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