Provider Demographics
NPI:1831493030
Name:EVIDENCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:EVIDENCE PHYSICAL THERAPY, LLC
Other - Org Name:EVIDENCEPT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HASSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:SHRM-CP
Authorized Official - Phone:301-352-8370
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9183
Mailing Address - Country:US
Mailing Address - Phone:301-352-8370
Mailing Address - Fax:301-352-8372
Practice Address - Street 1:12150 ANNAPOLIS RD STE 201
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769
Practice Address - Country:US
Practice Address - Phone:301-352-8370
Practice Address - Fax:301-352-8372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD218462251X0800X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
616235300OtherWORKERS COMPENSATION NUMBER
MD045308100Medicaid