Provider Demographics
NPI:1528248036
Name:RIVERVIEW PHYSICAL THERAPY AND REHAB,LLC
Entity type:Organization
Organization Name:RIVERVIEW PHYSICAL THERAPY AND REHAB,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:HARGOPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:TEKUMULLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:810-966-9102
Mailing Address - Street 1:1702 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4136
Mailing Address - Country:US
Mailing Address - Phone:810-966-9102
Mailing Address - Fax:810-966-9104
Practice Address - Street 1:1702 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4136
Practice Address - Country:US
Practice Address - Phone:810-966-9102
Practice Address - Fax:810-966-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003768225X00000X
MI5501008202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00311258OtherRAILROAD MEDICARE,PT
P00312642OtherRAILROAD MEDICARE ,OT,
MI48102OtherHEALTH PLAN OF MICHIGAN
MI4863011Medicaid
MI670G411150OtherBCBS OF MICHIGAN FOR OCCUPATIONAL THERAPY
MI164232OtherGREAT LAKES HEATH PLAN
MI650G411130OtherBCBS OF MICHIGAN FOR PHYSICAL THERAPY
MI080738OtherHAP OF MI
MI080738OtherHAP OF MI
OP28300Medicare PIN