Provider Demographics
NPI:1881911584
Name:CAPITOL REHAB OF CROFTON INC
Entity type:Organization
Organization Name:CAPITOL REHAB OF CROFTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCLENNY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-451-3561
Mailing Address - Street 1:1625 CROFTON CTR
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1318
Mailing Address - Country:US
Mailing Address - Phone:410-451-3561
Mailing Address - Fax:410-451-2265
Practice Address - Street 1:1625 CROFTON CTR
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1318
Practice Address - Country:US
Practice Address - Phone:410-451-3561
Practice Address - Fax:410-451-2265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03452261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1104941509OtherNPI TYPE 1
MD64671401OtherCAREFIRST
MDK7710001OtherBLUECROSS BLUESHIELD
MD=========OtherTIN