Provider Demographics
NPI:1104240845
Name:WALTROUS REHABILITATION MEDICINE ASSOCIATES LLC
Entity type:Organization
Organization Name:WALTROUS REHABILITATION MEDICINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTROUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-460-4661
Mailing Address - Street 1:8701 HAYSHED LN APT 34
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2841
Mailing Address - Country:US
Mailing Address - Phone:240-460-4661
Mailing Address - Fax:
Practice Address - Street 1:7610 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-4701
Practice Address - Country:US
Practice Address - Phone:301-817-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD77249261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty