1134168305 NPI number — REHABILITATION MEDICINE PHYSICIANS PC

Table of content: (NPI 1134168305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134168305 NPI number — REHABILITATION MEDICINE PHYSICIANS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REHABILITATION MEDICINE PHYSICIANS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134168305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3960 PATIENT CARE WAY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48911-4275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-351-8123
Provider Business Mailing Address Fax Number:
517-351-1352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3960 PATIENT CARE WAY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48911-4275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-351-8123
Provider Business Practice Location Address Fax Number:
517-351-1352
Provider Enumeration Date:
06/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VENTOCILLA
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
517-351-8123

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  CV405064 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0331111 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 25008734 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".