Healthcare Provider Details

I. General information

NPI: 1720312903
Provider Name (Legal Business Name): ERGO OCCMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6196 OXON HILL RD SUITE 120
OXON HILL MD
20745-3100
US

IV. Provider business mailing address

6196 OXON HILL RD STE 120
OXON HILL MD
20745-3138
US

V. Phone/Fax

Practice location:
  • Phone: 301-567-6400
  • Fax: 202-318-8174
Mailing address:
  • Phone: 301-567-6400
  • Fax: 202-318-8174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT870468
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19226
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: OLU PETER EZEANI
Title or Position: OWNER/PROVIDER
Credential:
Phone: 301-567-6400