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NPI Code Detail

MEDICARE: GLEN BURNIE PHYSICAL THERAPY & SPORTSCARE, LLC

MEDICARE: GLEN BURNIE PHYSICAL THERAPY & SPORTSCARE, LLC
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
1225X00000XOccupational Therapist
2225100000XPhysical Therapist

General Provider Information

NPI Number : 1679630073
Entity Type Code : Organization
Provider Name (Legal Business Name) : GLEN BURNIE PHYSICAL THERAPY & SPORTSCARE, LLC
Provider Business Mailing Address
First Line : 2122 YORK RD STE 300
Second Line :
City : OAK BROOK
State : IL
Zip : 60523-1925
Country : US
Telephone Number : 252-248-3313
Fax Number : 410-648-4878
Provider Business Practice Location Address
First Line : 5500 KNOLL NORTH DR STE 150
Second Line :
City : COLUMBIA
State : MD
Zip : 21045-2476
Country : US
Telephone Number : 443-542-0062
Fax Number : 443-542-0250
Authorized Official
Title or Position : CREDENTIALING MANAGER
Name : TASHEDA BROUGHTON
Credential :
Telephone Number : 252-248-3313
Provider Enumeration Date : 01/03/2007
Last Update Date : 11/01/2024

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