Provider Demographics
NPI:1366718330
Name:MI SPORTS REHAB P.C
Entity type:Organization
Organization Name:MI SPORTS REHAB P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINOTH
Authorized Official - Middle Name:S
Authorized Official - Last Name:PURUSOTHAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:248-208-7492
Mailing Address - Street 1:25865 W 12 MILE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1817
Mailing Address - Country:US
Mailing Address - Phone:248-208-7492
Mailing Address - Fax:248-208-7494
Practice Address - Street 1:25865 W 12 MILE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1817
Practice Address - Country:US
Practice Address - Phone:248-208-7492
Practice Address - Fax:248-208-7494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006612225100000X
MI5501006095225100000X
MI5201000744225X00000X
MI12080163235Z00000X
MI5501006291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty