Healthcare Provider Details

I. General information

NPI: 1992824486
Provider Name (Legal Business Name): INJURY TREATMENT CENTER OF MARYLAND,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8660 LIBERTY RD
RANDALLSTOWN MD
21133-4707
US

IV. Provider business mailing address

8660 LIBERTY RD
RANDALLSTOWN MD
21133-4707
US

V. Phone/Fax

Practice location:
  • Phone: 410-922-2300
  • Fax:
Mailing address:
  • Phone: 410-922-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: EVAN J WAGENHEIM
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 410-922-2300