Basic Information
Provider Information | |||||||||
NPI: | 1487067260 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SETON HEALTH CORPORATION OF SOUTHEASTERN MICHIGAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SHELBY PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28000 DEQUINDRE ROAD | ||||||||
Address2: | REVENUE CYCLE DEPARTMENT | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480921215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486808000 | ||||||||
FaxNumber: | 2482923852 | ||||||||
Practice Location | |||||||||
Address1: | 17900 23 MILE RD | ||||||||
Address2: | SUITE 401 | ||||||||
City: | MACOMB | ||||||||
State: | MI | ||||||||
PostalCode: | 480441161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5868689040 | ||||||||
FaxNumber: | 5868689013 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2014 | ||||||||
LastUpdateDate: | 06/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STARKEL | ||||||||
AuthorizedOfficialFirstName: | SARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2486808121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   | MI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
ID | Type | State | Issuer | Description | 30789 | 01 | MI | BCBSM | OTHER |