Provider Demographics
NPI:1992824486
Name:INJURY TREATMENT CENTER OF MARYLAND,LLC
Entity Type:Organization
Organization Name:INJURY TREATMENT CENTER OF MARYLAND,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGENHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-922-2300
Mailing Address - Street 1:8660 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4707
Mailing Address - Country:US
Mailing Address - Phone:410-922-2300
Mailing Address - Fax:
Practice Address - Street 1:8660 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4707
Practice Address - Country:US
Practice Address - Phone:410-922-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD208D00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty