Healthcare Provider Details

I. General information

NPI: 1437503802
Provider Name (Legal Business Name): 9109 LIBERTY ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 LIBERTY RD
RANDALLSTOWN MD
21133-3521
US

IV. Provider business mailing address

9109 LIBERTY RD
RANDALLSTOWN MD
21133-3521
US

V. Phone/Fax

Practice location:
  • Phone: 410-655-7373
  • Fax:
Mailing address:
  • Phone: 410-655-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03031
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number03031
License Number StateMD

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752