Provider Demographics
NPI:1538282827
Name:PHYSICAL THERAPY AND PAIN MANAGEMENT CENTER LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AND PAIN MANAGEMENT CENTER LLC
Other - Org Name:WHITE OAK PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-592-8200
Mailing Address - Street 1:11120 NEW HAMPSHIRE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2633
Mailing Address - Country:US
Mailing Address - Phone:301-592-8200
Mailing Address - Fax:301-592-8300
Practice Address - Street 1:11120 NEW HAMPSHIRE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-2633
Practice Address - Country:US
Practice Address - Phone:301-592-8200
Practice Address - Fax:301-592-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21045261QR0400X
DCPT870409261QR0400X
DC870427261QR0400X
332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413765500Medicaid
DCG02642Medicare PIN