1972727212 NPI number — MILLENNIUM PT & REHAB SERVICES, PC

Table of content: (NPI 1972727212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972727212 NPI number — MILLENNIUM PT & REHAB SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLENNIUM PT & REHAB SERVICES, 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:
MILLENNIUM PHYSICAL THERAPY REHABILITATION AND WELLNESS.
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:
1972727212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5245 WEST PIERSON ROAD.
Provider Second Line Business Mailing Address:
SUITE-2
Provider Business Mailing Address City Name:
FLUSHING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48433-3244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-732-2252
Provider Business Mailing Address Fax Number:
810-732-4303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5245 W PIERSON RD
Provider Second Line Business Practice Location Address:
SUITE-2
Provider Business Practice Location Address City Name:
FLUSHING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48433-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-732-2252
Provider Business Practice Location Address Fax Number:
810-732-4303
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOHANTY
Authorized Official First Name:
SUBHASIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-732-2252

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501006170 , 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: 4501335 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 650B557140 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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