Provider Demographics
NPI:1992578231
Name:INTERSTATE REHAB
Entity type:Organization
Organization Name:INTERSTATE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:586-530-7114
Mailing Address - Street 1:1000 JOHN R RD STE 114
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-4317
Mailing Address - Country:US
Mailing Address - Phone:248-850-8745
Mailing Address - Fax:248-843-0044
Practice Address - Street 1:1000 JOHN R RD STE 114
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4317
Practice Address - Country:US
Practice Address - Phone:248-850-8745
Practice Address - Fax:248-843-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty