Provider Demographics
NPI:1245618925
Name:EGONUS BALTIMORE PRO THERAPY AND REHABILITATION PA
Entity Type:Organization
Organization Name:EGONUS BALTIMORE PRO THERAPY AND REHABILITATION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:EGONU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-473-9747
Mailing Address - Street 1:416 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-6714
Mailing Address - Country:US
Mailing Address - Phone:410-238-2636
Mailing Address - Fax:410-238-2601
Practice Address - Street 1:416 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-6714
Practice Address - Country:US
Practice Address - Phone:410-238-2636
Practice Address - Fax:410-238-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD504430Medicare PIN
MD5254Medicare PIN