Basic Information
| Provider Information | |||||||||
| NPI: | 1962673285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UZNIS-DWIGHT PHYSICAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42615 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864122845 | ||||||||
| FaxNumber: | 5864161497 | ||||||||
| Practice Location | |||||||||
| Address1: | 18101 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482241382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138815678 | ||||||||
| FaxNumber: | 3138819337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | DWIGHT | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | HOWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2488664364 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 30392 | 01 | MI | BCBSM | OTHER | 0094960002 | 05 | MI | MEDICAID |