Basic Information
Provider Information | |||||||||
NPI: | 1003199464 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUDDY | ||||||||
FirstName: | JANA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT - PHYSICAL THERAP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MANNINO | ||||||||
OtherFirstName: | JANA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT - PHYSICAL THERAP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1048 N. MONROE ST. | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | MI | ||||||||
PostalCode: | 48162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342411400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1048 N. MONROE ST. | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | MI | ||||||||
PostalCode: | 48162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342411400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2011 | ||||||||
LastUpdateDate: | 07/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501016729 | MI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X |   | IN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2255A2300X | 99048678A | IN | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.