Provider Demographics
NPI:1104997972
Name:SOUTHSIDE REHAB ASSOCIATES
Entity type:Organization
Organization Name:SOUTHSIDE REHAB ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:FINOS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:517-333-8550
Mailing Address - Street 1:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-0558
Mailing Address - Country:US
Mailing Address - Phone:517-333-8550
Mailing Address - Fax:517-333-8539
Practice Address - Street 1:616 MEIJER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-8376
Practice Address - Country:US
Practice Address - Phone:517-333-8550
Practice Address - Fax:517-333-8539
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHSIDE REHAB ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001463261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236712Medicare ID - Type UnspecifiedMEDICARE ID NUMBER