Basic Information
| Provider Information | |||||||||
| NPI: | 1003817909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN SPINE & ORTHOPEDIC REHAB INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4918 W CLARK RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345729800 | ||||||||
| FaxNumber: | 7345720762 | ||||||||
| Practice Location | |||||||||
| Address1: | 4918 W CLARK RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345729800 | ||||||||
| FaxNumber: | 7345720762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7345729800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 5501003609 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 30382 | 01 | MI | BCBS | OTHER | 5691619 | 01 | AETNA | OTHER | RT810006 | 01 | MI | M CARE | OTHER | 100136 | 01 | CARE CHOICES | OTHER | 366180 | 01 | MI | HAP | OTHER |