Provider Demographics
NPI:1376841148
Name:MOSADDEGH PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:MOSADDEGH PHYSICAL THERAPY INC
Other - Org Name:PHYSICAL THERAPY AND SPORTS MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO, CFO
Authorized Official - Prefix:
Authorized Official - First Name:SASAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALEZAMINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-446-1644
Mailing Address - Street 1:17902 GEORGIA AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-2279
Mailing Address - Country:US
Mailing Address - Phone:240-774-0222
Mailing Address - Fax:240-774-0223
Practice Address - Street 1:7500 HANOVER PARKWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770
Practice Address - Country:US
Practice Address - Phone:301-446-1644
Practice Address - Fax:301-446-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD490853Medicare UPIN