Provider Demographics
NPI:1134866809
Name:INDIGO ROLAND PARK LLC
Entity type:Organization
Organization Name:INDIGO ROLAND PARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUFLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:410-279-8231
Mailing Address - Street 1:600 WYNDHURST AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2424
Mailing Address - Country:US
Mailing Address - Phone:410-601-3991
Mailing Address - Fax:
Practice Address - Street 1:600 WYNDHURST AVE STE 102
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2424
Practice Address - Country:US
Practice Address - Phone:410-601-3991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-16
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy