Provider Demographics
NPI:1336416684
Name:SCARBOROUGH, EDMUND (PT)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:SCARBOROUGH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1510 ROCK SPRING RD
Practice Address - Street 2:SUITE C
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2851
Practice Address - Country:US
Practice Address - Phone:410-420-3619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEP01037043OtherMEDICARE RAILROAD
MD232884Y5FMedicare PIN