Provider Demographics
NPI:1396770400
Name:RENAISSANCE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:RENAISSANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-775-5267
Mailing Address - Street 1:30020 SCHOENHERR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-775-5267
Mailing Address - Fax:586-775-2331
Practice Address - Street 1:30200 SCHOENHERR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-775-5267
Practice Address - Fax:586-775-2331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4792395Medicaid
MI71010000030669OtherBCBS
=========OtherPPOM
=========OtherTHERAMATRIX
MI4792395Medicaid