Healthcare Provider Details

I. General information

NPI: 1710502380
Provider Name (Legal Business Name): MARYLAND SPORTSCARE & REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 DORCHESTER AVE STE B
CAMBRIDGE MD
21613-2425
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 410-228-5100
  • Fax:
Mailing address:
  • Phone: 252-248-3313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TASHEDA BROUGHTON
Title or Position: MANAGER, CREDENTIALING
Credential: PESC
Phone: 252-248-3313