Basic Information
| Provider Information | |||||||||
| NPI: | 1215697826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MARYLAND MEDICAL REGIONAL PROFESSIONAL SERVICES, LLC | ||||||||
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| OtherOrganizationName: | TOWSON SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7601 OSLER DR | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212047700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103371000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4900 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212102600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103374024 | ||||||||
| FaxNumber: | 4439914582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2021 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4103371000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
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.