Healthcare Provider Details

I. General information

NPI: 1134397722
Provider Name (Legal Business Name): FREDERICK SPORT & SPINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WEST FREDERICK STREET
WALKERSVILLE MD
21793
US

IV. Provider business mailing address

84 THOMAS JOHNSON CT SUITE B
FREDERICK MD
21702-4348
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-8541
  • Fax:
Mailing address:
  • Phone: 301-662-8541
  • Fax: 301-662-8762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number17003
License Number StateMD

VIII. Authorized Official

Name: MS. CONNIE F GOODING
Title or Position: BILLING SPECIALIST
Credential:
Phone: 301-662-8541