Provider Demographics
NPI:1548487796
Name:MICHIGAN ORTHOPEDIC REHAB
Entity type:Organization
Organization Name:MICHIGAN ORTHOPEDIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-625-6400
Mailing Address - Street 1:7164 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1569
Mailing Address - Country:US
Mailing Address - Phone:248-625-6400
Mailing Address - Fax:248-625-6006
Practice Address - Street 1:7164 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-1569
Practice Address - Country:US
Practice Address - Phone:248-625-6400
Practice Address - Fax:248-625-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010511225100000X
MI5501300664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N96240Medicare ID - Type UnspecifiedPHYSICAL THERAPY