Provider Demographics
NPI:1073732632
Name:SHORTER PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SHORTER PHYSICAL THERAPY PC
Other - Org Name:EXCEL PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:301-860-0237
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:MD
Mailing Address - Zip Code:20758-0160
Mailing Address - Country:US
Mailing Address - Phone:310-860-0237
Mailing Address - Fax:301-860-0076
Practice Address - Street 1:3140 W WARD RD STE 203
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-3047
Practice Address - Country:US
Practice Address - Phone:410-286-7205
Practice Address - Fax:410-286-7206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS109OtherBLUE CROSS GROUP # FOR DC
MD7094369OtherAETNA GROUP#
MDKCB9EXOtherBLUE CROSS GROUP# MD SIDE
MDKCB9EXOtherBLUE CROSS GROUP# MD SIDE
DCG01022Medicare PIN