Basic Information
| Provider Information | |||||||||
| NPI: | 1235484676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMEUSE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5246 N ROYAL DR STE B | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496846984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319290303 | ||||||||
| FaxNumber: | 2319290305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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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 | 2251X0800X | 5501015699 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 5501015699 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01332469 | 01 | MI | RAILROAD MEDICARE | OTHER |