1528248036 NPI number — RIVERVIEW PHYSICAL THERAPY AND REHAB,LLC

Table of content: (NPI 1528248036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528248036 NPI number — RIVERVIEW PHYSICAL THERAPY AND REHAB,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERVIEW PHYSICAL THERAPY AND REHAB,LLC
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:
1528248036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1702 WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060-4136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-966-9102
Provider Business Mailing Address Fax Number:
810-966-9104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1702 WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-966-9102
Provider Business Practice Location Address Fax Number:
810-966-9104
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TEKUMULLA
Authorized Official First Name:
HARGOPAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
810-966-9102

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501008202 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 5201003768 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00311258 . This is a "RAILROAD MEDICARE,PT" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00312642 . This is a "RAILROAD MEDICARE ,OT," identifier . This identifiers is of the category "OTHER".
  • Identifier: 48102 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4863011 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 670G411150 . This is a "BCBS OF MICHIGAN FOR OCCUPATIONAL THERAPY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 164232 . This is a "GREAT LAKES HEATH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 650G411130 . This is a "BCBS OF MICHIGAN FOR PHYSICAL THERAPY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080738 . This is a "HAP OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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