1750597324 NPI number — PROFESSIONAL PT AND REHAB PC

Table of content: (NPI 1750597324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750597324 NPI number — PROFESSIONAL PT AND REHAB PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PT AND REHAB 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:
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:
1750597324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31150 HOOVER RD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48093-7618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-268-1929
Provider Business Mailing Address Fax Number:
586-268-1933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31150 HOOVER RD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-7618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-268-1929
Provider Business Practice Location Address Fax Number:
586-268-1933
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AHLUWALIA
Authorized Official First Name:
SMITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-582-9907

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501005394 , 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: 104696147 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 650F339030 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 125076 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 650019090 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P106004 . This is a "BLUECARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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