Basic Information
| Provider Information | |||||||||
| NPI: | 1558522318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAXIMUM PERFORMANCE PHYSICAL THERAPY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14435 CHERRY LANE CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207074959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017763665 | ||||||||
| FaxNumber: | 3017766669 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 BLAIR DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211131343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106728970 | ||||||||
| FaxNumber: | 4106728973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3017766669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19310 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4578031 01 | 05 | MD | MEDICAID |