Provider Demographics
NPI:1912166463
Name:ACCREDITED PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:ACCREDITED PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTVIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:586-427-6641
Mailing Address - Street 1:27733 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6641
Mailing Address - Country:US
Mailing Address - Phone:586-427-6641
Mailing Address - Fax:586-427-6642
Practice Address - Street 1:5889 WHITMORE LAKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1998
Practice Address - Country:US
Practice Address - Phone:810-229-7931
Practice Address - Fax:810-229-7931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare PIN