Basic Information
| Provider Information | |||||||||
| NPI: | 1932316940 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HIMMELMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2725 N WESTWOOD BLVD | ||||||||
| Address2: | SUITE 17 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864277 | ||||||||
| FaxNumber: | 5736864406 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 PHYSICIANS PARK | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737789348 | ||||||||
| FaxNumber: | 5736864870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 10/29/2013 | ||||||||
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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 | PT2966 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | PT2966 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | PT2966 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 2011037087 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 2011037087 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 2251S0007X | 2011037087 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
ID Information
| ID | Type | State | Issuer | Description | 164036721 | 05 | AR | MEDICAID |