1134519838 NPI number — EVOLUTION SPORTS PHYSIOTHERAPY - WHITE MARSH, LLC

Table of content: (NPI 1134519838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134519838 NPI number — EVOLUTION SPORTS PHYSIOTHERAPY - WHITE MARSH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUTION SPORTS PHYSIOTHERAPY - WHITE MARSH, 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:
1134519838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11605 CROSSROADS CIR
Provider Second Line Business Mailing Address:
D-E
Provider Business Mailing Address City Name:
MIDDLE RIVER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220-2865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-955-3515
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10540 YORK RD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
COCKEYSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21030-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-955-3515
Provider Business Practice Location Address Fax Number:
410-628-0542
Provider Enumeration Date:
02/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MORGAN
Authorized Official Middle Name:
SANDFORD
Authorized Official Title or Position:
OWNER / PARTNET
Authorized Official Telephone Number:
443-955-3515

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  20554 , 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)





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