Organization
FREDERICKS SPORT AND SPINE CLINIC INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
C GOODING (CREDENTIALLING OFFICER)
(301) 662-8541
Entity
Organization
Contact information
Practice address
84 THOMAS JOHNSON CT, SUITE B, FREDERICK, MD 21702-4348
(301) 662-8541
(301) 662-8762
Mailing address
84 THOMAS JOHNSON CT, SUITE B, FREDERICK, MD 21702-4348
(301) 662-8541
(301) 662-8762
Taxonomy
Speciality
Code
Description
License number
State
2251X0800X
Orthopedic Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
123M
MEDICARE
MD
01
—
147719000
DEPT OF LABOR
MD
01
—
551810
MAMSI
MD
Enumeration date
07/28/2006
Last updated
06/04/2014
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