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NPI Code Detail

MEDICARE: DENISE SAMPLE P.T.A.

MEDICARE: DENISE SAMPLE P.T.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208100000XPhysical Medicine & Rehabilitation PhysicianA1975MD

General Provider Information

NPI Number : 1114100625
Entity Type Code : Individual
Provider Name (Legal Business Name) : DENISE SAMPLE P.T.A.
Provider Business Mailing Address
First Line : 6011 UNIVERSITY BLVD
Second Line : SUITE 120
City : ELLICOTT CITY
State : MD
Zip : 21043-6074
Country : US
Telephone Number : 410-203-0391
Fax Number : 410-203-2707
Provider Business Practice Location Address
First Line : 6011 UNIVERSITY BLVD
Second Line : SUITE 120
City : ELLICOTT CITY
State : MD
Zip : 21043-6074
Country : US
Telephone Number : 410-203-0391
Fax Number : 410-203-2707
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/07/2007
Last Update Date : 12/01/2011

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Directions to “ DENISE SAMPLE P.T.A.” Practice Location

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