Provider Demographics
NPI:1932208535
Name:INDIVIDUALIZED PHYSICAL THERAPY & REHAB P.C.
Entity type:Organization
Organization Name:INDIVIDUALIZED PHYSICAL THERAPY & REHAB P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PANACHAKUNNIL JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-946-2504
Mailing Address - Street 1:44633 JOY RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1730
Mailing Address - Country:US
Mailing Address - Phone:734-710-6600
Mailing Address - Fax:734-710-3002
Practice Address - Street 1:44633 JOY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187
Practice Address - Country:US
Practice Address - Phone:734-710-6600
Practice Address - Fax:734-710-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30381OtherBLUE CROSS BLUE SHIELD
MI236846Medicare ID - Type Unspecified
MI236846Medicare PIN