Basic Information
| Provider Information | |||||||||
| NPI: | 1457524738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-ATLANTIC SPORTS THERAPY & REHABILITATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 BENSON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212271056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106441880 | ||||||||
| FaxNumber: | 4106446048 | ||||||||
| Practice Location | |||||||||
| Address1: | 3421 BENSON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212271056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106441880 | ||||||||
| FaxNumber: | 4106446048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | MADDOCK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4106441880 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.