Basic Information
| Provider Information | |||||||||
| NPI: | 1407173859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN MARYLAND PHYSICAL THERAPY INC. | ||||||||
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| OtherOrganizationName: | REHABILITATION CENTER OF SOUTHERN MARYLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7503 SURRATTS RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Practice Location | |||||||||
| Address1: | 22715 WASHINGTON STREET | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LEONARDTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019970172 | ||||||||
| FaxNumber: | 3019970175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHIARAMONTE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3018774530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 219378700 OT | 05 | MD | MEDICAID | 196518200 PT | 05 | MD | MEDICAID |