Provider Demographics
NPI:1376990200
Name:WHITE MARSH HEALTHCARE PHYSICAL MEDICINE,LLC
Entity Type:Organization
Organization Name:WHITE MARSH HEALTHCARE PHYSICAL MEDICINE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-725-4930
Mailing Address - Street 1:5430 CAMPBELL BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-5500
Mailing Address - Country:US
Mailing Address - Phone:443-725-4930
Mailing Address - Fax:410-657-7478
Practice Address - Street 1:5430 CAMPBELL BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162-5500
Practice Address - Country:US
Practice Address - Phone:443-725-4930
Practice Address - Fax:410-657-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory