Provider Demographics
NPI:1083624969
Name:HEALTH SOURCE PHYSICAL THERAPY CENTER, INC.
Entity type:Organization
Organization Name:HEALTH SOURCE PHYSICAL THERAPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAYA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BODDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-647-1000
Mailing Address - Street 1:1447 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1631
Mailing Address - Country:US
Mailing Address - Phone:517-647-1000
Mailing Address - Fax:517-647-1100
Practice Address - Street 1:1447 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1631
Practice Address - Country:US
Practice Address - Phone:517-647-1000
Practice Address - Fax:517-647-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005495261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30472OtherBCN
MIP109760OtherBCN
MI64-00030OtherPHP
MI650C457010OtherBCBS
MI10-4266217Medicaid
MI5501005495OtherPRIORITY HEALTH
MI650C457010OtherBCBS