Provider Demographics
NPI:1083096499
Name:REVOLUTION SPORTS MEDICINE
Entity Type:Organization
Organization Name:REVOLUTION SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LOUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:240-512-0190
Mailing Address - Street 1:6570 DOBBIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5855
Mailing Address - Country:US
Mailing Address - Phone:240-512-0190
Mailing Address - Fax:240-512-0192
Practice Address - Street 1:6570 DOBBIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5855
Practice Address - Country:US
Practice Address - Phone:240-512-0190
Practice Address - Fax:240-512-0192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty