Provider Demographics
NPI:1306158985
Name:GUDE, SRINIVASA RAO (RPT)
Entity type:Individual
Prefix:MR
First Name:SRINIVASA
Middle Name:RAO
Last Name:GUDE
Suffix:
Gender:M
Credentials:RPT
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Mailing Address - Street 1:5511 W US HIGHWAY 10
Mailing Address - Street 2:SUITE # B
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2455
Mailing Address - Country:US
Mailing Address - Phone:231-845-0900
Mailing Address - Fax:231-845-0909
Practice Address - Street 1:340 ECORSE RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5734
Practice Address - Country:US
Practice Address - Phone:734-483-1000
Practice Address - Fax:734-483-1010
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501014309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501014309OtherSTATE OF MI