Provider Demographics
NPI:1114108545
Name:CANTON ORTHOPAEDIC & SPORTS REHABILITATION INC
Entity Type:Organization
Organization Name:CANTON ORTHOPAEDIC & SPORTS REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-522-6978
Mailing Address - Street 1:801 UMBRA ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224
Mailing Address - Country:US
Mailing Address - Phone:410-522-6978
Mailing Address - Fax:410-522-0290
Practice Address - Street 1:808 S CONKLING ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224
Practice Address - Country:US
Practice Address - Phone:410-522-6978
Practice Address - Fax:410-522-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty