Basic Information
| Provider Information | |||||||||
| NPI: | 1528079696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONROE ORTHOPEDIC THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42615 GARFIELD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864122846 | ||||||||
| FaxNumber: | 5862860427 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 N TELEGRAPH ROAD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342424866 | ||||||||
| FaxNumber: | 7342423559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | DWIGHT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2488664364 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650E810940 | 01 | BC | OTHER |