Provider Demographics
NPI:1255389169
Name:LEMOINE, GREGORY KEITH (PT, DPT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:KEITH
Last Name:LEMOINE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 RACE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2376
Mailing Address - Country:US
Mailing Address - Phone:410-918-0080
Mailing Address - Fax:410-918-0050
Practice Address - Street 1:1232 RACE RD STE 203
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2376
Practice Address - Country:US
Practice Address - Phone:410-918-0080
Practice Address - Fax:410-918-0050
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLV17OtherCAREFIRST BLUECROSS/SHIEL
MDE705-0004OtherFEDERAL BLUECROSS/SHIELD