Provider Demographics
NPI:1306928841
Name:NORTHSHORE REHAB PLLC
Entity type:Organization
Organization Name:NORTHSHORE REHAB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT S CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-947-5071
Mailing Address - Street 1:901 W FRONT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2374
Mailing Address - Country:US
Mailing Address - Phone:231-947-5071
Mailing Address - Fax:231-947-5094
Practice Address - Street 1:901 W FRONT ST
Practice Address - Street 2:SUITE B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2374
Practice Address - Country:US
Practice Address - Phone:231-947-5071
Practice Address - Fax:231-947-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010135612081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2552810134OtherBCBS PIN #
MI4673607Medicaid
MI4673607Medicaid
MI2552810134OtherBCBS PIN #