1043496250 NPI number — PHYSICAL MEDICINE, P.C.

Table of content: (NPI 1043496250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043496250 NPI number — PHYSICAL MEDICINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL MEDICINE, P.C.
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:
JACK BELEN, M.D.
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:
1043496250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20307 W. 12 MILE
Provider Second Line Business Mailing Address:
STE. 102
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-356-6661
Provider Business Mailing Address Fax Number:
248-356-6619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20307 W 12 MILE RD
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-5407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-356-6661
Provider Business Practice Location Address Fax Number:
248-356-6619
Provider Enumeration Date:
01/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BELEN
Authorized Official First Name:
JACK
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-365-6661

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  042374 , 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: 1552582 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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