Provider Demographics
NPI:1700193463
Name:BAXTER, JEREMY S (PT, ATC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:BAXTER
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8174 LARK BROWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6426
Mailing Address - Country:US
Mailing Address - Phone:410-799-9988
Mailing Address - Fax:410-799-9986
Practice Address - Street 1:8174 LARK BROWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6426
Practice Address - Country:US
Practice Address - Phone:410-799-9988
Practice Address - Fax:410-799-9986
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23368225100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer