Healthcare Provider Details

I. General information

NPI: 1770764490
Provider Name (Legal Business Name): BLUE WATER PHYSIATRY L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 SURRATTS ROAD #202
CLINTON MD
20735-2256
US

IV. Provider business mailing address

6368 COVENTRY WAY #365
CLINTON MD
20735-2256
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-6110
  • Fax: 301-877-2695
Mailing address:
  • Phone: 301-877-6110
  • Fax: 301-877-2695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberD0039416
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD0039416
License Number StateMD

VIII. Authorized Official

Name: ARTHUR PETER BARLETTA
Title or Position: PRESIDENT
Credential: MD
Phone: 301-877-6110