Healthcare Provider Details

I. General information

NPI: 1497967327
Provider Name (Legal Business Name): MARYLAND PHYSICAL THERAPY GROUP, INC. TA MID-TOWNE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 E MOUNT ROYAL AVE THE TOWNE BLDG LOWER LEVEL
BALTIMORE MD
21202-2714
US

IV. Provider business mailing address

11 EAST MOUNT ROYAL AVE THE TOWNE BLDG LOWER LEVEL
BALTIMORE MD
21202-2714
US

V. Phone/Fax

Practice location:
  • Phone: 410-347-3000
  • Fax: 410-539-3676
Mailing address:
  • Phone: 410-347-3000
  • Fax: 410-539-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberD0006489
License Number StateMD

VIII. Authorized Official

Name: PROF. M. SUSAN MATTHEWSON
Title or Position: COORDINATOR
Credential:
Phone: 410-347-3000