1649480674 NPI number — GREAT LAKES THERAPY HOUSE CALLS PC

Table of content: (NPI 1649480674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649480674 NPI number — GREAT LAKES THERAPY HOUSE CALLS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES THERAPY HOUSE CALLS 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:
GREAT LAKES PHYSICAL THERAPY CENTER
Provider Other Organization Name Type Code:
3
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:
1649480674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 BARLOW ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49686-4721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-941-8100
Provider Business Mailing Address Fax Number:
231-922-0382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5123 N ROYAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-9201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-941-8100
Provider Business Practice Location Address Fax Number:
231-941-8812
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
231-941-8100

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 670B8 . This is a "BCBS MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 650B8 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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