Provider Demographics
NPI:1699772475
Name:DANE, MICHAEL ANDREW (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:DANE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1579 STRAITS TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1835
Mailing Address - Country:US
Mailing Address - Phone:203-577-2002
Mailing Address - Fax:203-577-2060
Practice Address - Street 1:1579 STRAITS TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1835
Practice Address - Country:US
Practice Address - Phone:203-577-2002
Practice Address - Fax:203-577-2060
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004207389Medicaid
CT080006422CT07OtherANTHEM BLUE CROSS SHIELD
CT650016540OtherRAILROAD MEDICARE
CT080006422CT07OtherANTHEM BLUE CROSS SHIELD