Basic Information
Provider Information | |||||||||
NPI: | 1699911321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ISENBERG | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | EMILY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NESTLERODE | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | EMILY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 130 HOSPITAL RD | ||||||||
Address2: | STE 103 | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105358180 | ||||||||
FaxNumber: | 4105358325 | ||||||||
Practice Location | |||||||||
Address1: | 120 HOSPITAL RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105358180 | ||||||||
FaxNumber: | 4105358325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2008 | ||||||||
LastUpdateDate: | 04/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 22735 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 406409700 | 05 | MD |   | MEDICAID |