Basic Information
| Provider Information | |||||||||
| NPI: | 1184718058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUANTUM PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1613 S HURON ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481979701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344839200 | ||||||||
| FaxNumber: | 7344839202 | ||||||||
| Practice Location | |||||||||
| Address1: | 1613 S HURON ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481979701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344839200 | ||||||||
| FaxNumber: | 7344839202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | MAROVINO | ||||||||
| AuthorizedOfficialFirstName: | TIZIANO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7344839200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501004580 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0H10432 | 01 | MI | BCBSM | OTHER | 0H11582 | 01 | MI | BCBSM | OTHER |