NPIMap

Organization Active NPI

Sports Pro Physical Therapy LLC

  • Physical Therapist
  • Upper Marlboro, MD
National Provider Identifier
1285611608
Registry record updated Sep 1, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
18090 Issued in MD
Legal business name
SPORTS PRO PHYSICAL THERAPY LLC
Practice address
9440 Pennsylvania Ave
# 215
Upper Marlboro, MD 20772
Phone
(301) 599-8899
Fax
(301) 599-8878
NPI assigned
Dec 28, 2005
Last updated
Sep 1, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 1, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Daryl Andrew Clarke, PTNPI 1689709719
Title
Director of PT Owner
Phone
(301) 599-8899

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X 2800 DC
Physical Therapist 225100000X 18090 MD Primary

Addresses

Primary practice location

9440 Pennsylvania Ave
# 215
Upper Marlboro, MD 20772

Mailing address

12200 Annapolis Rd
#119
Glenn Dale, MD 20769-9182
Phone (301) 599-8899

Other identifiers 10

IdentifierTypeStateIssuer
466223OtherMAMSI PROVIDER NUMBER
3204256OtherAETNA HMO
523780OtherNCPPO PROVIDER
101837200OtherDOL OWCP
2320527OtherUNITED HEALTHCARE MID ATL
KER3SPOtherGRP CAREFIRST BLUE CROSS
270001084OtherCORVEL
7910288OtherAETNA PPO
H853001OtherCAREFIRST BLUE CROSS BLUE
68640202OtherPROVIDER CAREFIRST BLUECR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in DC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080801000088 DC Part B Supplier - Clinic/Group Practice 4688748106 Receives reassigned benefits from 9 practitioners
Practice locations: Glenn Dale, MD; Upper Marlboro, MD

National Provider Directory

National Provider Directory
Tax ID family
Sports Pro Physical Therapy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

9440 Pennsylvania Ave
Ste 215
Uppr Marlboro, MD 20772
Phone (301) 599-8899

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1135728000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1441065600000",
    "number": "1285611608",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12200 ANNAPOLIS RD",
            "address_2": "#119",
            "city": "GLENN DALE",
            "state": "MD",
            "postal_code": "207699182",
            "telephone_number": "301-599-8899",
            "fax_number": "301-599-8878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9440 PENNSYLVANIA AVE",
            "address_2": "# 215",
            "city": "UPPER MARLBORO",
            "state": "MD",
            "postal_code": "20772",
            "telephone_number": "301-599-8899",
            "fax_number": "301-599-8878"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPORTS PRO PHYSICAL THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-28",
        "last_updated": "2015-09-01",
        "status": "A",
        "authorized_official_last_name": "CLARKE",
        "authorized_official_first_name": "DARYL",
        "authorized_official_middle_name": "ANDREW",
        "authorized_official_title_or_position": "DIRECTOR OF PT OWNER",
        "authorized_official_telephone_number": "301-599-8899",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "DC",
            "license": "2800",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "MD",
            "license": "18090",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAMSI PROVIDER NUMBER",
            "identifier": "466223",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA HMO",
            "identifier": "3204256",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPPO PROVIDER",
            "identifier": "523780",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DOL OWCP",
            "identifier": "101837200",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE MID ATL",
            "identifier": "2320527",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GRP CAREFIRST BLUE CROSS",
            "identifier": "KER3SP",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CORVEL",
            "identifier": "270001084",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA PPO",
            "identifier": "7910288",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAREFIRST BLUE CROSS BLUE",
            "identifier": "H853001",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PROVIDER CAREFIRST BLUECR",
            "identifier": "68640202",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Upper Marlboro, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.