Provider Demographics
NPI:1649390840
Name:PHYSICAL THERAPY PROFESSIONAL CENTER INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY PROFESSIONAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST PRESIDENT CORP
Authorized Official - Prefix:
Authorized Official - First Name:NATALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GERACHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:301-990-1449
Mailing Address - Street 1:17B FIRSTFIELD RD
Mailing Address - Street 2:STE 105
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878
Mailing Address - Country:US
Mailing Address - Phone:301-990-1449
Mailing Address - Fax:301-990-1016
Practice Address - Street 1:17B FIRSTFIELD RD
Practice Address - Street 2:STE 105
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878
Practice Address - Country:US
Practice Address - Phone:301-990-1449
Practice Address - Fax:301-990-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3312816OtherAETNA POS
MD480182OtherMAMSI
MD110AOtherCAREFIRST
DCJ1080001OtherCAREFIRST
MD110AOtherBCBS
MD7097210OtherAETNA PPO
MD405806200Medicaid
MD3312816OtherAETNA HMO
DCJ1080001OtherBCBS
MD=========OtherGUARDIAN
DCJ1080001OtherCAREFIRST
MD=========OtherBCBS
MD=========OtherCIGNA
DCJ1080001OtherBCBS
MDQ05189Medicare UPIN
MD6P01Medicare ID - Type UnspecifiedPROVIDER
DCJ1080001OtherBCBS
MD480182OtherMAMSI
MD7097210OtherAETNA PPO