Provider Demographics
NPI:1285611608
Name:SPORTS PRO PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SPORTS PRO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-599-8899
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:#119
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-599-8899
Mailing Address - Fax:301-599-8878
Practice Address - Street 1:9440 PENNSYLVANIA AVE
Practice Address - Street 2:# 215
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772
Practice Address - Country:US
Practice Address - Phone:301-599-8899
Practice Address - Fax:301-599-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2800225100000X
MD18090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
68640202OtherPROVIDER CAREFIRST BLUECR
7910288OtherAETNA PPO
H853001OtherCAREFIRST BLUE CROSS BLUE
2320527OtherUNITED HEALTHCARE MID ATL
270001084OtherCORVEL
466223OtherMAMSI PROVIDER NUMBER
523780OtherNCPPO PROVIDER
KER3SPOtherGRP CAREFIRST BLUE CROSS
101837200OtherDOL OWCP
3204256OtherAETNA HMO
3204256OtherAETNA HMO
H853001OtherCAREFIRST BLUE CROSS BLUE
68640202OtherPROVIDER CAREFIRST BLUECR