Basic Information
| Provider Information | |||||||||
| NPI: | 1053477935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMBRIDGE PHYSICAL THERAPY AND SPORTS CARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROFESSIONAL PHYSICAL THERAPY AND SPORTS CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4108204330 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 DORCHESTER AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216132425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102285100 | ||||||||
| FaxNumber: | 4102287479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THROCKMORTON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9192582714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | 402750700 | 05 | MD | MEDICAID | 827311 | 01 | MD | PRIORITY PARTNERS | OTHER | G540 | 01 | BCHOICE-FED BC | OTHER | KDE4 | 01 | MD | BC | OTHER |