Healthcare Provider Details

I. General information

NPI: 1104240845
Provider Name (Legal Business Name): WALTROUS REHABILITATION MEDICINE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 PENNSYLVANIA AVE
DISTRICT HEIGHTS MD
20747-4701
US

IV. Provider business mailing address

8701 HAYSHED LN APT 34
COLUMBIA MD
21045-2841
US

V. Phone/Fax

Practice location:
  • Phone: 301-817-3001
  • Fax:
Mailing address:
  • Phone: 240-460-4661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberD77249
License Number StateMD

VIII. Authorized Official

Name: DR. JUSTIN WALTROUS
Title or Position: OWNER
Credential: M.D.
Phone: 240-460-4661