1285611608 NPI number — SPORTS PRO PHYSICAL THERAPY LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285611608 NPI number — SPORTS PRO PHYSICAL THERAPY LLC

Employer Identification Number (EIN):

Provider Organization Name:

SPORTS PRO PHYSICAL THERAPY 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 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:

1285611608

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

09/01/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

12200 ANNAPOLIS RD

Provider Second Line Business Mailing Address:

#119

Provider Business Mailing Address City Name:

GLENN DALE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

20769-9182

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

301-599-8899

Provider Business Mailing Address Fax Number:

301-599-8878

Provider First Line Business Practice Location Address:

9440 PENNSYLVANIA AVE

Provider Second Line Business Practice Location Address:

# 215

Provider Business Practice Location Address City Name:

UPPER MARLBORO

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

20772

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

301-599-8899

Provider Business Practice Location Address Fax Number:

301-599-8878

Provider Enumeration Date:

12/28/2005

Authorized Official Last Name:

CLARKE

Authorized Official First Name:

DARYL

Authorized Official Middle Name:

ANDREW

Authorized Official Title or Position:

DIRECTOR OF PT OWNER

Authorized Official Telephone Number:

301-599-8899

• Taxonomy code: 225100000X , with the licence number:  18090 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 225100000X , with the licence number: 2800 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 68640202 . This is a "PROVIDER CAREFIRST BLUECR" identifier . This identifiers is of the category "OTHER".
• Identifier: 7910288 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
• Identifier: H853001 . This is a "CAREFIRST BLUE CROSS BLUE" identifier . This identifiers is of the category "OTHER".
• Identifier: 2320527 . This is a "UNITED HEALTHCARE MID ATL" identifier . This identifiers is of the category "OTHER".
• Identifier: 270001084 . This is a "CORVEL" identifier . This identifiers is of the category "OTHER".
• Identifier: 466223 . This is a "MAMSI PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 523780 . This is a "NCPPO PROVIDER" identifier . This identifiers is of the category "OTHER".
• Identifier: KER3SP . This is a "GRP CAREFIRST BLUE CROSS" identifier . This identifiers is of the category "OTHER".
• Identifier: 101837200 . This is a "DOL OWCP" identifier . This identifiers is of the category "OTHER".
• Identifier: 3204256 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".