Provider Demographics
NPI:1407955651
Name:PENINSULA REHABILITATION & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:PENINSULA REHABILITATION & SPORTS MEDICINE, INC.
Other - Org Name:PENINSULA REHAB & SPORTS MEDICINE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, PT, ATC
Authorized Official - Phone:410-213-7878
Mailing Address - Street 1:12417 OCEAN GTWY STE 9
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9522
Mailing Address - Country:US
Mailing Address - Phone:410-213-7878
Mailing Address - Fax:410-213-7879
Practice Address - Street 1:12417 OCEAN GTWY STE 9
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9522
Practice Address - Country:US
Practice Address - Phone:410-213-7878
Practice Address - Fax:410-213-7879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19831225100000X, 2251S0007X
MD19532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty