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General NPI Number Information
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NPI Number | 1598506552
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Entity Type | Organization
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Legal Business Name | IMPACT SPORTS & SPINE LLC
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Dates
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Enumeration Date | 06/04/2024
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 9420 KEY WEST AVE STE 325
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City | ROCKVILLE
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State | MD
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Zip | 20850-6529
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Country | US
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Telephone | 703-789-3216
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Fax |
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Provider Business Mailing Address
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Address Line | 9420 KEY WEST AVE STE 325
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City | ROCKVILLE
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State | MD
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Zip | 20850-6529
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-FOUNDER/PHYSICIAN
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Name | DAVID ITSKEVICH
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Credential | DO
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Telephone | 301-363-9693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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