Provider Demographics
NPI:1700918943
Name:BREDEN, JEREMY B (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:B
Last Name:BREDEN
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 1:1377 MOTOR PKWY
Mailing Address - Street 2:STE 307
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:1406B CRAIN HWY S
Practice Address - Street 2:SUITE 107
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4099
Practice Address - Country:US
Practice Address - Phone:410-590-2334
Practice Address - Fax:410-590-2336
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP86445Medicare ID - Type UnspecifiedPHYSICAL THERAPY