Provider Demographics
NPI:1386699031
Name:THUNDER BAY THERAPY & SPORTS MEDICINE, PLC
Entity type:Organization
Organization Name:THUNDER BAY THERAPY & SPORTS MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSCIAL THERAPIST
Authorized Official - Phone:989-358-8086
Mailing Address - Street 1:348 LONG RAPIDS PLZ
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1374
Mailing Address - Country:US
Mailing Address - Phone:989-358-8086
Mailing Address - Fax:989-354-2253
Practice Address - Street 1:348 LONG RAPIDS PLZ
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1374
Practice Address - Country:US
Practice Address - Phone:989-358-8086
Practice Address - Fax:989-354-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30720OtherBLUE CROSS &BS
MI30720OtherBLUE CROSS &BS
MI236747Medicare Oscar/Certification