Basic Information
Provider Information | |||||||||
NPI: | 1790392058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THORNBURG | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 225 N CALVERT ST APT 1038 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212024949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3047804256 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1207 LIBERTY RD # 106 | ||||||||
Address2: |   | ||||||||
City: | ELDERSBURG | ||||||||
State: | MD | ||||||||
PostalCode: | 217846574 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105495700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2020 | ||||||||
LastUpdateDate: | 10/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT004346 | WV | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 28140 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.