Healthcare Provider Details

I. General information

NPI: 1861963167
Provider Name (Legal Business Name): BODYWORKS MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12805 OLD FORT RD STE 301
FORT WASHINGTON MD
20744-2814
US

IV. Provider business mailing address

12805 OLD FORT RD STE 301
FORT WASHINGTON MD
20744-2814
US

V. Phone/Fax

Practice location:
  • Phone: 301-658-7338
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EMMA CULL
Title or Position: COO
Credential:
Phone: 678-469-5011