Healthcare Provider Details

I. General information

NPI: 1265208268
Provider Name (Legal Business Name): MADISON GILLEN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9030 OLD ANNAPOLIS RD STE B
COLUMBIA MD
21045-1990
US

IV. Provider business mailing address

7526 MAIN ST APT B
SYKESVILLE MD
21784-7385
US

V. Phone/Fax

Practice location:
  • Phone: 443-979-8535
  • Fax:
Mailing address:
  • Phone: 774-274-7326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number29716
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: