Basic Information
| Provider Information | |||||||||
| NPI: | 1912447244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAZAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 S US HIGHWAY 27 STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488792423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892241424 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 S US HIGHWAY 27 STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488792423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892241424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2017 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501013922 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.