1336290063 NPI number — MR. STEPHEN FREEMAN MPT, ATC

Table of content: MR. STEPHEN FREEMAN MPT, ATC (NPI 1336290063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336290063 NPI number — MR. STEPHEN FREEMAN MPT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN
Provider First Name:
STEPHEN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPT, ATC
Provider Gender Code:
M

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:
1336290063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 FAIRMOUNT AVE
Provider Second Line Business Mailing Address:
STE 302
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-5494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-927-8768
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2977 MANCHESTER RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21102-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-374-8410
Provider Business Practice Location Address Fax Number:
410-374-8409
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  19451 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 19451 , 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: 47610189 . This is a "CAREFIRST BCBS PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 69772203 . This is a "BCBS REGION RENDERING #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 44565 . This is a "IWIF PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 310822 . This is a "MDIPA, MAMSI, OPT CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7647074 . This is a "AETNA PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 310822 . This is a "ALLIANCE PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 023348001 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1939107 . This is a "UNITEDHEALTHCARE PROVIDER" identifier . This identifiers is of the category "OTHER".




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