1497101836 NPI number — DRAYER PHYSICAL THERAPY OF MARYLAND LLC

Table of content: ELIZABETH DAKOTA GLICKSON MD (NPI 1710780077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497101836 NPI number — DRAYER PHYSICAL THERAPY OF MARYLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRAYER PHYSICAL THERAPY OF MARYLAND 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:
1497101836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3455 HIGHWAY 81
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30052-9138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-554-0665
Provider Business Mailing Address Fax Number:
770-554-0685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 BEL AIR SOUTH PKWY
Provider Second Line Business Practice Location Address:
SUITE 503B
Provider Business Practice Location Address City Name:
BEL AIR
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21015-6091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-399-9590
Provider Business Practice Location Address Fax Number:
410-399-9591
Provider Enumeration Date:
05/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
717-220-2100

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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