Provider Demographics
NPI:1093954158
Name:ADVANCE PHYSICAL THERAPY & SPORTS REHAB. INC
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY & SPORTS REHAB. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:CUBA
Authorized Official - Last Name:RUTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:301-570-3588
Mailing Address - Street 1:3411 OLANDWOOD CT
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1488
Mailing Address - Country:US
Mailing Address - Phone:240-750-9966
Mailing Address - Fax:301-774-1336
Practice Address - Street 1:3411 OLANDWOOD CT
Practice Address - Street 2:SUITE 106
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1488
Practice Address - Country:US
Practice Address - Phone:240-750-9966
Practice Address - Fax:301-774-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18214261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD355103200Medicaid
MD355103200Medicaid