Healthcare Provider Details

I. General information

NPI: 1427609429
Provider Name (Legal Business Name): ACTIVE SPINE & REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 CROMWELL PARK DR
GLEN BURNIE MD
21061-2563
US

IV. Provider business mailing address

10753 BIRMINGHAM WAY
WOODSTOCK MD
21163-1535
US

V. Phone/Fax

Practice location:
  • Phone: 410-970-8190
  • Fax: 410-313-8314
Mailing address:
  • Phone: 410-970-8190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICK MURRAY
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 410-970-8190