Provider Demographics
NPI:1952300436
Name:MANUAL PT & SPORTS MEDICINE
Entity Type:Organization
Organization Name:MANUAL PT & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:ROVNAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:410-889-8004
Mailing Address - Street 1:PO BOX 50105
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-4105
Mailing Address - Country:US
Mailing Address - Phone:410-889-8004
Mailing Address - Fax:410-889-8024
Practice Address - Street 1:3612 FALLS RD LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1814
Practice Address - Country:US
Practice Address - Phone:410-889-8004
Practice Address - Fax:410-889-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ353MAOtherCAREFIRST BC/BS MARYLAND
P20586Medicare UPIN
MDJ353MAOtherCAREFIRST BC/BS MARYLAND