Provider Demographics
NPI:1578165718
Name:HIBBS, CONNOR
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:HIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21826-2115
Mailing Address - Country:US
Mailing Address - Phone:443-534-4678
Mailing Address - Fax:
Practice Address - Street 1:11007 MANKLIN CREEK RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-4012
Practice Address - Country:US
Practice Address - Phone:410-208-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist