1639618267 NPI number — PHYSICAL THERAPY MANAGEMENT MI LLC

Table of content: JERAMIE LYNN ROSALES RODRIGUEZ M.D. (NPI 1205290319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639618267 NPI number — PHYSICAL THERAPY MANAGEMENT MI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY MANAGEMENT MI 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:
1639618267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 431361
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48343-1361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-747-3497
Provider Business Mailing Address Fax Number:
800-980-3329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 W HURON ST
Provider Second Line Business Practice Location Address:
SUITE # G70
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-747-3497
Provider Business Practice Location Address Fax Number:
800-980-3329
Provider Enumeration Date:
02/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SHKOUKANI
Authorized Official First Name:
RAWAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
586-202-6706

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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