Provider Demographics
NPI:1164958435
Name:PHYSICAL THERAPY AT CROSSROADS, LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AT CROSSROADS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS
Authorized Official - Phone:443-393-3788
Mailing Address - Street 1:4801 DORSEY HALL DR STE 130
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7763
Mailing Address - Country:US
Mailing Address - Phone:443-393-3788
Mailing Address - Fax:443-378-3533
Practice Address - Street 1:4801 DORSEY HALL DR STE 130
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7763
Practice Address - Country:US
Practice Address - Phone:443-393-3788
Practice Address - Fax:443-378-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20452261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD695106600Medicaid