Basic Information
Provider Information | |||||||||
NPI: | 1447605035 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIVOT PHYSICAL THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10995 OWINGS MILLS BLVD | ||||||||
Address2: | SUITE 210 | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211171019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106542300 | ||||||||
FaxNumber: | 4433788645 | ||||||||
Practice Location | |||||||||
Address1: | 10995 OWINGS MILLS BLVD | ||||||||
Address2: | SUITE 210 | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211171019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106542300 | ||||||||
FaxNumber: | 4433788645 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2016 | ||||||||
LastUpdateDate: | 05/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADAAN | ||||||||
AuthorizedOfficialFirstName: | DEEPALI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 4103826641 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MPT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 25739 | MD | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.