Provider Demographics
NPI:1134519838
Name:EVOLUTION SPORTS PHYSIOTHERAPY - WHITE MARSH, LLC
Entity type:Organization
Organization Name:EVOLUTION SPORTS PHYSIOTHERAPY - WHITE MARSH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PARTNET
Authorized Official - Prefix:DR
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:SANDFORD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:443-955-3515
Mailing Address - Street 1:11605 CROSSROADS CIR
Mailing Address - Street 2:D-E
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2865
Mailing Address - Country:US
Mailing Address - Phone:443-955-3515
Mailing Address - Fax:
Practice Address - Street 1:10540 YORK RD
Practice Address - Street 2:SUITE F
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2300
Practice Address - Country:US
Practice Address - Phone:443-955-3515
Practice Address - Fax:410-628-0542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20554261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy