Basic Information
| Provider Information | |||||||||
| NPI: | 1013558410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TALJONICK | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 S MILL ST | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484202307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106878700 | ||||||||
| FaxNumber: | 8106878724 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S MILL ST | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484202307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106878700 | ||||||||
| FaxNumber: | 8106878724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5501019336 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | 5501019336 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501019336 | 01 | MI | STATE OF MICHIGAN | OTHER |