Healthcare Provider Details

I. General information

NPI: 1780213991
Provider Name (Legal Business Name): JEREMIAH J GOROSPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 TOLEDO TER STE A1
HYATTSVILLE MD
20782-4136
US

IV. Provider business mailing address

14205 PARK CENTER DR STE 204
LAUREL MD
20707-5252
US

V. Phone/Fax

Practice location:
  • Phone: 301-853-0093
  • Fax: 301-853-0096
Mailing address:
  • Phone: 301-853-0093
  • Fax: 301-853-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberN2968
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: