Healthcare Provider Details

I. General information

NPI: 1033829841
Provider Name (Legal Business Name): MADISON BROOKE TAMBERINO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADISON BROOKE DIETZ DPT

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LEWIS LN STE 104
HAVRE DE GRACE MD
21078-3752
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 410-939-8530
  • Fax:
Mailing address:
  • Phone: 866-370-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30312
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT030567
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: