Provider Demographics
NPI:1932561644
Name:MARYLAND SPORTSCARE & REHAB LLC
Entity Type:Organization
Organization Name:MARYLAND SPORTSCARE & REHAB LLC
Other - Org Name:PIVOT PHYSICAL THERAPY OF MARYLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:7310 RITCHIE HWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3065
Mailing Address - Country:US
Mailing Address - Phone:410-766-4047
Mailing Address - Fax:
Practice Address - Street 1:14700 BALTIMORE AVE
Practice Address - Street 2:STE 106
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:240-754-2203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty