1871794669 NPI number — GREAT LAKES PHYSICAL MEDICINE AND REHABILITATION

Table of content: (NPI 1871794669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871794669 NPI number — GREAT LAKES PHYSICAL MEDICINE AND REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES PHYSICAL MEDICINE AND REHABILITATION
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:
1871794669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3247 BIDDLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYANDOTTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48192-5951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-287-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3247 BIDDLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYANDOTTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48192-5951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-287-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ABRAHAMSON
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PHYSICIAN
Authorized Official Telephone Number:
313-304-4818

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  078199 , 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)





Copyright © 2007-2025 www.npivalidator.com