Healthcare Provider Details

I. General information

NPI: 1134731987
Provider Name (Legal Business Name): SUMEDH SHIVKUMAR DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 GALLANT FOX LN STE 115
BOWIE MD
20715-4031
US

IV. Provider business mailing address

14205 PARK CENTER DR STE 204
LAUREL MD
20707-5252
US

V. Phone/Fax

Practice location:
  • Phone: 301-853-0093
  • Fax: 301-853-0096
Mailing address:
  • Phone: 301-853-0093
  • Fax: 301-853-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27997
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: