Basic Information
Provider Information | |||||||||
NPI: | 1053595199 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR PHYSICAL MEDICINE AND REHABILITATION PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMPLETE ORTHOTICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13850 E 12 MILE RD | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480883730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5865524499 | ||||||||
FaxNumber: | 5865524878 | ||||||||
Practice Location | |||||||||
Address1: | 13850 E 12 MILE RD | ||||||||
Address2: | STE 2-B | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480883730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5865524499 | ||||||||
FaxNumber: | 5865524878 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2007 | ||||||||
LastUpdateDate: | 12/26/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRASNICK | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | ALAN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5865524499 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | MI | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 540E020680 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |