Provider Demographics
NPI:1497967327
Name:MARYLAND PHYSICAL THERAPY GROUP, INC. TA MID-TOWNE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MARYLAND PHYSICAL THERAPY GROUP, INC. TA MID-TOWNE MEDICAL GROUP, INC.
Other - Org Name:MID-TOWNE MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:M. SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-347-3000
Mailing Address - Street 1:11 EAST MOUNT ROYAL AVE
Mailing Address - Street 2:THE TOWNE BLDG LOWER LEVEL
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2714
Mailing Address - Country:US
Mailing Address - Phone:410-347-3000
Mailing Address - Fax:410-539-3676
Practice Address - Street 1:11 E MOUNT ROYAL AVE
Practice Address - Street 2:THE TOWNE BLDG LOWER LEVEL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2714
Practice Address - Country:US
Practice Address - Phone:410-347-3000
Practice Address - Fax:410-539-3676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0006489261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLS50MIMedicare UPIN