Basic Information
| Provider Information | |||||||||
| NPI: | 1780724617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALVERT PHYSICAL THERAPY AND SPORTS FITNESS CTR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105358180 | ||||||||
| FaxNumber: | 4105358325 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105358180 | ||||||||
| FaxNumber: | 4105358325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 10/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | SMOOTZ | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4104144846 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | 261QP2000X | 15757 | MD | 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 | 406409700 | 05 | MD | MEDICAID |