Provider Demographics
NPI:1154519064
Name:ORTHOPEDIC SPINE AND SPORTS THERAPY INC
Entity type:Organization
Organization Name:ORTHOPEDIC SPINE AND SPORTS THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-992-1500
Mailing Address - Street 1:54945 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-6028
Mailing Address - Country:US
Mailing Address - Phone:586-992-1500
Mailing Address - Fax:586-992-8050
Practice Address - Street 1:54945 MOUND RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-6028
Practice Address - Country:US
Practice Address - Phone:586-992-1500
Practice Address - Fax:586-992-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P29920Medicare PIN