Provider Demographics
NPI:1386990687
Name:MID-ATLANTIC SPINAL REHAB & CHIROPRACTIC PC
Entity type:Organization
Organization Name:MID-ATLANTIC SPINAL REHAB & CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GULITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:443-500-4444
Mailing Address - Street 1:2001 EASTERN AVE
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3061
Mailing Address - Country:US
Mailing Address - Phone:443-842-5500
Mailing Address - Fax:443-842-5501
Practice Address - Street 1:2001 EASTERN AVE STE 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-3061
Practice Address - Country:US
Practice Address - Phone:443-842-5500
Practice Address - Fax:443-842-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03660111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
791518OtherOPTUM HEALTHCARE
AC670001OtherCAREFIRST BLUE CROSS AND BLUE SHIELD
1962661405OtherINDIVIDUAL PROVIDER NPI