1619988789 NPI number — WAGNER PHYSICAL THERAPY INC

Table of content: (NPI 1619988789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619988789 NPI number — WAGNER PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAGNER PHYSICAL THERAPY INC
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:
1619988789
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:
42615 GARFIELD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-412-2846
Provider Business Mailing Address Fax Number:
586-286-0427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARLETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-635-3660
Provider Business Practice Location Address Fax Number:
989-635-3662
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DWIGHT
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER ADMINISTRATOR
Authorized Official Telephone Number:
248-866-4364

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 30758 . This is a "BC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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