Provider Demographics
NPI:1770764490
Name:BLUE WATER PHYSIATRY L L C
Entity type:Organization
Organization Name:BLUE WATER PHYSIATRY L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BARLETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-877-6110
Mailing Address - Street 1:6368 COVENTRY WAY
Mailing Address - Street 2:#365
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2256
Mailing Address - Country:US
Mailing Address - Phone:301-877-6110
Mailing Address - Fax:301-877-2695
Practice Address - Street 1:7501 SURRATTS ROAD
Practice Address - Street 2:#202
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2256
Practice Address - Country:US
Practice Address - Phone:301-877-6110
Practice Address - Fax:301-877-2695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE WATER PHYSIATRY L L C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-21
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00394162081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE69508Medicare UPIN
MD5796950001Medicare NSC
DCG01261Medicare PIN
MD646MMedicare PIN