Provider Demographics
NPI:1043663206
Name:GBMC-WP-PT
Entity Type:Organization
Organization Name:GBMC-WP-PT
Other - Org Name:ACTIVE LIFE PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAH
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT,OCS
Authorized Official - Phone:410-227-1417
Mailing Address - Street 1:4337 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-2143
Mailing Address - Country:US
Mailing Address - Phone:410-529-3303
Mailing Address - Fax:410-529-7980
Practice Address - Street 1:1447 YORK RD
Practice Address - Street 2:SUITE 401
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6017
Practice Address - Country:US
Practice Address - Phone:410-529-3303
Practice Address - Fax:410-529-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPENDINGOtherMEDICARE
MD=========OtherCOMMERCIAL