Provider Demographics
NPI:1457524738
Name:MID-ATLANTIC SPORTS THERAPY & REHABILITATION, LLC
Entity Type:Organization
Organization Name:MID-ATLANTIC SPORTS THERAPY & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-644-1880
Mailing Address - Street 1:3421 BENSON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-1056
Mailing Address - Country:US
Mailing Address - Phone:410-644-1880
Mailing Address - Fax:410-644-6048
Practice Address - Street 1:3421 BENSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-1056
Practice Address - Country:US
Practice Address - Phone:410-644-1880
Practice Address - Fax:410-644-6048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty