Provider Demographics
NPI:1134397722
Name:FREDERICK SPORT & SPINE CLINIC
Entity type:Organization
Organization Name:FREDERICK SPORT & SPINE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:F
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 1:19 WEST FREDERICK STREET
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793
Practice Address - Country:US
Practice Address - Phone:301-662-8541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDERICK SPORT & SPINE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD170032251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD123MOtherMEDICARE
MDLK93FRROtherCAREFIRST
MD334552OtherPHCS
MD551810OtherMAMSI
MD2004876OtherUNITED HEALTHCARE
MDR559OtherCAREFIRST NAL'L