Provider Demographics
NPI:1376536565
Name:AFFINITY SPORTS & REHABILITAION PHYSICAL THERAPY
Entity Type:Organization
Organization Name:AFFINITY SPORTS & REHABILITAION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIAT
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-562-1116
Mailing Address - Street 1:1105 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4026
Mailing Address - Country:US
Mailing Address - Phone:301-562-1116
Mailing Address - Fax:301-562-1317
Practice Address - Street 1:1105 SPRING ST
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4026
Practice Address - Country:US
Practice Address - Phone:301-562-1116
Practice Address - Fax:301-562-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18131261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG00193Medicare ID - Type Unspecified