Provider Demographics
NPI:1528586948
Name:MARYLAND SPORTS, SPINE AND MUSCULOSKELETAL INSTITUTE
Entity Type:Organization
Organization Name:MARYLAND SPORTS, SPINE AND MUSCULOSKELETAL INSTITUTE
Other - Org Name:MSSMI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTROUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-460-4661
Mailing Address - Street 1:2860 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3490
Mailing Address - Country:US
Mailing Address - Phone:240-460-4661
Mailing Address - Fax:
Practice Address - Street 1:8096 EDWIN RAYNOR BLVD STE C
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6837
Practice Address - Country:US
Practice Address - Phone:240-460-4661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00772492081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty