Healthcare Provider Details

I. General information

NPI: 1588124002
Provider Name (Legal Business Name): ZACHARY JAMES EGOLF PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 THIRD AVE STE 1000
SYKESVILLE MD
21784-5205
US

IV. Provider business mailing address

4575 DAVE RILL RD
HAMPSTEAD MD
21074-2531
US

V. Phone/Fax

Practice location:
  • Phone: 410-795-8800
  • Fax:
Mailing address:
  • Phone: 443-974-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA5117
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: