1871546739 NPI number — PORT HURON THERAPY CENTER LLC

Table of content: (NPI 1871546739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871546739 NPI number — PORT HURON THERAPY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT HURON THERAPY CENTER 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:
MIDWEST 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:
1871546739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34051 GRATIOT AVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48035-3592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-385-9808
Provider Business Mailing Address Fax Number:
586-415-7800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34051 GRATIOT AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48035-3592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-385-9808
Provider Business Practice Location Address Fax Number:
586-415-7800
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZAFAR
Authorized Official First Name:
MUHAMMAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
810-385-9808

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X , 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: 137801 . This is a "CARE CHOICES PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5135045 . This is a "CIGNA PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 142585 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30426 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4704356 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 234528 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 30322 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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