Basic Information
| Provider Information | |||||||||
| NPI: | 1518951995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYLAND SPORTSCARE & REHAB LLC | ||||||||
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| OtherOrganizationName: | PIVOT PHYSICAL THERAPY OF MARYLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE | ||||||||
| Address2: | STE 302 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109278768 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 844 WASHINGTON RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211576664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108765600 | ||||||||
| FaxNumber: | 4108761623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR, REVENUE CYCLE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4432254492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2160584 | 01 | UHC | OTHER | T208 | 01 | MD | BLUECHOICE | OTHER | 7914198 | 01 | AETNA | OTHER | 2160584 | 01 | ACN | OTHER |