Basic Information
| Provider Information | |||||||||
| NPI: | 1245676097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | TIFFANY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 N LUZERNE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212241115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179751066 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4337 EBENEZER RD | ||||||||
| Address2: | |||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212362143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105293303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23349 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | F517 | 01 | MD | BLUE CROSS BLUE SHIELD OF MARYLAND | OTHER |