Provider Demographics
NPI:1154868172
Name:PRIMEPHYSICALTHERAPYLLC
Entity Type:Organization
Organization Name:PRIMEPHYSICALTHERAPYLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WON
Authorized Official - Middle Name:
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:757-615-8409
Mailing Address - Street 1:1332 LONDONTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6587
Mailing Address - Country:US
Mailing Address - Phone:443-531-5888
Mailing Address - Fax:410-877-2002
Practice Address - Street 1:1332 LONDONTOWN BLVD
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6587
Practice Address - Country:US
Practice Address - Phone:443-531-5888
Practice Address - Fax:410-877-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23717261QP2000X
MD22451261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3099202 00Medicaid