Provider Demographics
NPI:1437368131
Name:PHYSICAL THERAPY TEAM PC
Entity type:Organization
Organization Name:PHYSICAL THERAPY TEAM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-618-1041
Mailing Address - Street 1:PO 21603
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221
Mailing Address - Country:US
Mailing Address - Phone:313-618-1041
Mailing Address - Fax:248-553-8420
Practice Address - Street 1:1640 WEBB ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-1350
Practice Address - Country:US
Practice Address - Phone:313-618-1041
Practice Address - Fax:248-991-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N17040Medicare ID - Type Unspecified