Healthcare Provider Details

I. General information

NPI: 1962176743
Provider Name (Legal Business Name): SAGE PHYSICAL THERAPY & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405B S JEFFERSON ST
FREDERICK MD
21701-6272
US

IV. Provider business mailing address

PO BOX 745944
ATLANTA GA
30374-5944
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-9335
  • Fax: 301-662-9337
Mailing address:
  • Phone: 410-970-8177
  • Fax: 410-313-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: TODD SIGMON
Title or Position: INTERIM CCO
Credential:
Phone: 410-970-8190