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General NPI Number Information
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NPI Number | 1083096499
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Entity Type | Organization
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Legal Business Name | REVOLUTION SPORTS MEDICINE
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Dates
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Enumeration Date | 06/22/2015
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 6570 DOBBIN RD
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City | COLUMBIA
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State | MD
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Zip | 21045-5855
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Country | US
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Telephone | 240-512-0190
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Fax | 240-512-0192
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Provider Business Mailing Address
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Address Line | 6570 DOBBIN RD
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City | COLUMBIA
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State | MD
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Zip | 21045-5855
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Country | US
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Telephone | 240-512-0190
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Fax | 240-512-0192
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. TIMOTHY P. LOUGHLIN
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Credential | DPT
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Telephone | 240-512-0190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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