Provider Demographics
NPI:1992764492
Name:EXECUTIVE REHABILITATION & SPORTS THERAPY, INC.
Entity type:Organization
Organization Name:EXECUTIVE REHABILITATION & SPORTS THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SARGEANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-816-0020
Mailing Address - Street 1:6000 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE #201
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3803
Mailing Address - Country:US
Mailing Address - Phone:301-816-0020
Mailing Address - Fax:301-816-0334
Practice Address - Street 1:6000 EXECUTIVE BLVD
Practice Address - Street 2:SUITE #201
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3803
Practice Address - Country:US
Practice Address - Phone:301-816-0020
Practice Address - Fax:301-816-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK366OtherBCBS/ NON PAR
MDK366OtherBCBS/ NON PAR