Healthcare Provider Details

I. General information

NPI: 1710375910
Provider Name (Legal Business Name): UNIVERSITY OF MARYLAND SPORTS MEDICINE AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 FIELD HOUSE DR
COLLEGE PARK MD
20742-5415
US

IV. Provider business mailing address

PO BOX 64380
BALTIMORE MD
21264-4380
US

V. Phone/Fax

Practice location:
  • Phone: 667-214-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MELANIE ROBIN
Title or Position: INCENTIVE PROGRAMS MANAGER
Credential:
Phone: 667-214-1069