Provider Demographics
NPI:1215240502
Name:MICHIGAN REHABILITATION PHYSICIANS
Entity type:Organization
Organization Name:MICHIGAN REHABILITATION PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:HANNA
Authorized Official - Last Name:GUMMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-367-2767
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-0093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17187 SCHAEFER HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4132
Practice Address - Country:US
Practice Address - Phone:313-367-2767
Practice Address - Fax:313-367-2818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086814208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID #