1972641488 NPI number — DAVID PHILBRICK ATC

Table of content: DAVID PHILBRICK ATC (NPI 1972641488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972641488 NPI number — DAVID PHILBRICK ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILBRICK
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
M

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:
1972641488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3540 RIVER OAKS BLVD
Provider Second Line Business Mailing Address:
APT. 3311
Provider Business Mailing Address City Name:
ROCHESTER HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48309-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-498-3519
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20952 E 12 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48081-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-498-3519
Provider Business Practice Location Address Fax Number:
586-498-3510
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  040302030 , 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)





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