Provider Demographics
NPI:1760491666
Name:MIDDLETOWN SPORT AND SPINE LLC
Entity Type:Organization
Organization Name:MIDDLETOWN SPORT AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-662-8541
Mailing Address - Street 1:84 THOMAS JOHNSON CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4348
Mailing Address - Country:US
Mailing Address - Phone:301-662-8541
Mailing Address - Fax:301-662-8762
Practice Address - Street 1:205 S. CHURCH STREET
Practice Address - Street 2:SUITE B
Practice Address - City:MIDDLETOWN
Practice Address - State:MD
Practice Address - Zip Code:21769
Practice Address - Country:US
Practice Address - Phone:301-662-8541
Practice Address - Fax:301-662-8762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD034NMedicare ID - Type Unspecified