Provider Demographics
NPI:1063432748
Name:EVANS, BRIAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-0179
Mailing Address - Country:US
Mailing Address - Phone:410-734-6556
Mailing Address - Fax:410-734-6557
Practice Address - Street 1:2304 E CHURCHVILLE RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-1721
Practice Address - Country:US
Practice Address - Phone:410-734-6556
Practice Address - Fax:410-734-6557
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD221MN616Medicare ID - Type Unspecified
MDQ65868Medicare UPIN