Provider Demographics
NPI:1104943380
Name:BARRIOS, JORGE GABRIEL (PT)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:GABRIEL
Last Name:BARRIOS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 PLEASANT PLACE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N8Y2EA
Mailing Address - Country:CA
Mailing Address - Phone:734-377-7298
Mailing Address - Fax:
Practice Address - Street 1:37650 PROFESSIONAL CENTER DRIVE SUITE 105A
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:734-953-1745
Practice Address - Fax:734-953-1743
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION95990004Medicare ID - Type Unspecified