Basic Information
Provider Information | |||||||||
NPI: | 1154553881 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UDDIN | ||||||||
FirstName: | SAMAH | ||||||||
MiddleName: | FIROZ | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 133 W MAIN ST | ||||||||
Address2: | 120 | ||||||||
City: | NORTHVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 481671547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483471168 | ||||||||
FaxNumber: | 2483471252 | ||||||||
Practice Location | |||||||||
Address1: | 133 W MAIN ST | ||||||||
Address2: | 120 | ||||||||
City: | NORTHVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 481671547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483471168 | ||||||||
FaxNumber: | 2483471252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2009 | ||||||||
LastUpdateDate: | 11/30/2012 | ||||||||
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 | 2251X0800X | PT24886 | FL | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 5501015859 | MI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.