Healthcare Provider Details

I. General information

NPI: 1043562051
Provider Name (Legal Business Name): SOUTH MOUNTAIN REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 SCHLEY AVE # F STE 595
BRADDOCK HEIGHTS MD
21714-7500
US

IV. Provider business mailing address

9722 MOUNT TABOR RD
MIDDLETOWN MD
21769-9523
US

V. Phone/Fax

Practice location:
  • Phone: 240-356-0330
  • Fax: 240-356-0340
Mailing address:
  • Phone: 240-818-8630
  • Fax: 240-356-0340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PENELOPE A MCQUARRIE
Title or Position: PT, PRESIDENT
Credential: PT
Phone: 240-818-8630