Healthcare Provider Details

I. General information

NPI: 1871936294
Provider Name (Legal Business Name): COLUMBIA MEDICAL SPORT & SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 SNOWDEN RIVER PKWY SUITE 103
COLUMBIA MD
21045-1982
US

IV. Provider business mailing address

8600 SNOWDEN RIVER PKWY SUITE 103
COLUMBIA MD
21045-1982
US

V. Phone/Fax

Practice location:
  • Phone: 410-720-5555
  • Fax: 410-381-4653
Mailing address:
  • Phone: 410-720-5555
  • Fax: 410-381-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD0051586
License Number StateMD

VIII. Authorized Official

Name: VAUGHAN DABBS
Title or Position: OWNER
Credential:
Phone: 410-599-6846