Basic Information
| Provider Information | |||||||||
| NPI: | 1225255672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UZNIS PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 BETSY ROSS DR | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485496407 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18101 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482241382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138815678 | ||||||||
| FaxNumber: | 3138819337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARVELL | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3138815678 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 5501001604 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 30392 | 01 | BLUE CROSS | OTHER | 0094960002 | 05 | MI | MEDICAID |