Provider Demographics
NPI:1174079545
Name:RESURGENT PERFORMANCE PT
Entity type:Organization
Organization Name:RESURGENT PERFORMANCE PT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:VAN ORNUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:240-261-6136
Mailing Address - Street 1:16810 OAKMONT AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-4110
Mailing Address - Country:US
Mailing Address - Phone:240-261-6136
Mailing Address - Fax:
Practice Address - Street 1:16810 OAKMONT AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-4110
Practice Address - Country:US
Practice Address - Phone:240-261-6136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25246261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy