Provider Demographics
NPI:1598506552
Name:IMPACT SPORTS & SPINE LLC
Entity type:Organization
Organization Name:IMPACT SPORTS & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ITSKEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-363-9693
Mailing Address - Street 1:9420 KEY WEST AVE STE 325
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9420 KEY WEST AVE STE 325
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6529
Practice Address - Country:US
Practice Address - Phone:703-789-3216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty