Basic Information
| Provider Information | |||||||||
| NPI: | 1639622202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITRO | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69030 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212649030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 5629 PLANK RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404450206 | ||||||||
| FaxNumber: | 5407397473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2016 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2305210462 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.