Basic Information
| Provider Information | |||||||||
| NPI: | 1346749488 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PATEL | ||||||||
| FirstName: | MONIL | ||||||||
| MiddleName: | I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2060 ROCHESTER RD | ||||||||
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| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831837 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 FORD ST | ||||||||
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| City: | HIGHLAND PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482033622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138833585 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2018 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501013857 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501013857 | 05 | MI | MEDICAID |