Healthcare Provider Details

I. General information

NPI: 1083022974
Provider Name (Legal Business Name): PROFESSIONAL SPORTSCARE AND REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 GRINDALL ST
BALTIMORE MD
21230-4103
US

IV. Provider business mailing address

203 GRINDALL ST
BALTIMORE MD
21230-4103
US

V. Phone/Fax

Practice location:
  • Phone: 410-884-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number25MT00193100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberA00308
License Number StateMD

VIII. Authorized Official

Name: CHAD PATTEE
Title or Position: PHYSICAL THERAPY DIRECTOR
Credential:
Phone: 410-884-6000