Basic Information
| Provider Information | |||||||||
| NPI: | 1710023916 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED NEURO REHAB SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26635 WOODWARD AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HUNTINGTON WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480701372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485486400 | ||||||||
| FaxNumber: | 2485488885 | ||||||||
| Practice Location | |||||||||
| Address1: | 26635 WOODWARD AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HUNTINGTON WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485486400 | ||||||||
| FaxNumber: | 2485488885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2485486400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | HP050806-4301050806 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4377860 | 05 | MI | MEDICAID |