Provider Demographics
NPI:1588962237
Name:ELITE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ELITE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-799-0818
Mailing Address - Street 1:8165 CYPRUS CEDAR LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-5559
Mailing Address - Country:US
Mailing Address - Phone:410-799-0818
Mailing Address - Fax:410-799-2653
Practice Address - Street 1:8165 CYPRUS CEDAR LN
Practice Address - Street 2:SUITE 205
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-5559
Practice Address - Country:US
Practice Address - Phone:410-799-0818
Practice Address - Fax:410-799-2653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD981LMedicare PIN