Basic Information
| Provider Information | |||||||||
| NPI: | 1912930835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FITNESS FORUM OF MARYLAND, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 659 S SALISBURY BLVD | ||||||||
| Address2: | SUITE 1B | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108605910 | ||||||||
| FaxNumber: | 4108605912 | ||||||||
| Practice Location | |||||||||
| Address1: | 2448 HOLLY AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102954941 | ||||||||
| FaxNumber: | 4102955207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | BALDWIN | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4105487600 | ||||||||
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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 | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1784629 | 01 | MD | UNITED HEALTHCARE | OTHER | 57731 | 01 | MD | JOHNS HOPKINS HEALTHCARE | OTHER | 147433400 | 01 | MD | ACS - US DEPT OF LABOR | OTHER | 2195313 | 01 | MD | CCN NETWORK | OTHER | T671 | 01 | DC | BCBS OF DC | OTHER | 147433401 | 01 | MD | ACS - US DEPT OF LABOR | OTHER | KC41FI | 01 | MD | BCBS OF MARYLAND | OTHER | 2195313 | 01 | MD | FIRST HEALTH NETWORK | OTHER |