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General NPI Number Information
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NPI Number | 1134397722
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Entity Type | Organization
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Legal Business Name | FREDERICK SPORT & SPINE CLINIC
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Dates
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Enumeration Date | 02/15/2008
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Last Update Date | 02/15/2008
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Provider Practice Location Address
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Address Line | 19 WEST FREDERICK STREET
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City | WALKERSVILLE
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State | MD
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Zip | 21793
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Country | US
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Telephone | 301-662-8541
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Fax |
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Provider Business Mailing Address
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Address Line | 84 THOMAS JOHNSON CT SUITE B
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City | FREDERICK
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State | MD
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Zip | 21702-4348
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Country | US
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Telephone | 301-662-8541
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Fax | 301-662-8762
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Authorized Official
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Title or Position | BILLING SPECIALIST
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Name | MS. CONNIE F GOODING
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Credential |
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Telephone | 301-662-8541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 17003
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License Number State | MD
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