Provider Demographics
NPI:1376793364
Name:CALVERT PHYSICAL THERAPY AND SPORTS FITNESS CENTER
Entity Type:Organization
Organization Name:CALVERT PHYSICAL THERAPY AND SPORTS FITNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMOOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-414-4846
Mailing Address - Street 1:130 HOSPITAL RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4022
Mailing Address - Country:US
Mailing Address - Phone:410-535-8180
Mailing Address - Fax:410-535-8325
Practice Address - Street 1:220 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3926
Practice Address - Country:US
Practice Address - Phone:410-535-3416
Practice Address - Fax:410-414-5930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15757332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406409703Medicaid
MD4113540004Medicare NSC