Provider Demographics
NPI:1851548317
Name:SPORT AND SPINE REHAB OF CHEVY CHASE
Entity Type:Organization
Organization Name:SPORT AND SPINE REHAB OF CHEVY CHASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:THIBODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:240-766-0300
Mailing Address - Street 1:11418 LIVINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:FT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5145
Mailing Address - Country:US
Mailing Address - Phone:240-766-0300
Mailing Address - Fax:240-766-0304
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-986-1701
Practice Address - Fax:240-766-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22286225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0700SPOtherBCBS OF MD
DCA518OtherBCBS NCA
MD718214OtherACN