Provider Demographics
NPI:1508892761
Name:PROFESSIONAL SPORTSCARE, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL SPORTSCARE, LLC
Other - Org Name:PIVOT PHYSICAL THERAPY OF MARYLAND/GREATER BALTIMORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-225-4492
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:
Practice Address - Street 1:2634 BRANDERMILL BLVD
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1651
Practice Address - Country:US
Practice Address - Phone:410-721-7201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
701076OtherACN
18GMMAOtherCAREFIRST BCBS OF MARYLAND
5120OtherBLUECHOICE/GHMSI
701076OtherACN