Provider Demographics
NPI:1184179202
Name:GLEN BURNIE PT & SPORTSCARE, LLC
Entity Type:Organization
Organization Name:GLEN BURNIE PT & SPORTSCARE, LLC
Other - Org Name:PIVOT PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:PESC
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:501 FAIRMOUNT AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5457
Mailing Address - Country:US
Mailing Address - Phone:410-927-8768
Mailing Address - Fax:
Practice Address - Street 1:3708 MOUNTAIN RD
Practice Address - Street 2:STE D
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2025
Practice Address - Country:US
Practice Address - Phone:410-255-4833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty