Provider Demographics
NPI:1376928556
Name:PENINSULA REHAB & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:PENINSULA REHAB & SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:WIST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-213-7878
Mailing Address - Street 1:12417 OCEAN GTWY
Mailing Address - Street 2:#9
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9521
Mailing Address - Country:US
Mailing Address - Phone:410-213-7878
Mailing Address - Fax:410-213-7879
Practice Address - Street 1:12913 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-4718
Practice Address - Country:US
Practice Address - Phone:410-213-7878
Practice Address - Fax:410-213-7879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENINSULA REHAB & SPORTS MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23989297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty