Provider Demographics
NPI:1194999441
Name:RADOMSKI, MICHAEL T (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:RADOMSKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:248-373-7600
Mailing Address - Fax:248-373-7443
Practice Address - Street 1:17272 ROBBINS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-256-8670
Practice Address - Fax:248-373-7443
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
M78170008Medicare PIN
MIM78170008Medicare PIN