Basic Information
| Provider Information | |||||||||
| NPI: | 1528569720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAYNOR | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 GREYSTONE CT NE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493411528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169152136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 235 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495035247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168408684 | ||||||||
| FaxNumber: | 6168409771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2018 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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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 | 2251X0800X | 5501012506 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 1437402542 | 05 | MI | MEDICAID |