Basic Information
Provider Information | |||||||||
NPI: | 1912528274 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DRAYER PHYSICAL THERAPY OF MARYLAND LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5300 DERRY ST FL 2 | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171113576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178392110 | ||||||||
FaxNumber: | 7175651934 | ||||||||
Practice Location | |||||||||
Address1: | 11710 E MARKET PLACE, SUITE F | ||||||||
Address2: |   | ||||||||
City: | FULTON | ||||||||
State: | MD | ||||||||
PostalCode: | 20759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3014900419 | ||||||||
FaxNumber: | 4104901260 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2020 | ||||||||
LastUpdateDate: | 05/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMAS | ||||||||
AuthorizedOfficialFirstName: | BEVERLY | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | PROV ENROLLMENT CRED SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 7178392159 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.