Provider Demographics
NPI:1003817909
Name:MICHIGAN SPINE & ORTHOPEDIC REHAB INC
Entity Type:Organization
Organization Name:MICHIGAN SPINE & ORTHOPEDIC REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:734-572-9800
Mailing Address - Street 1:4918 W CLARK RD
Mailing Address - Street 2:STE 102
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1142
Mailing Address - Country:US
Mailing Address - Phone:734-572-9800
Mailing Address - Fax:734-572-0762
Practice Address - Street 1:4918 W CLARK RD
Practice Address - Street 2:STE 102
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1142
Practice Address - Country:US
Practice Address - Phone:734-572-9800
Practice Address - Fax:734-572-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003609261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30382OtherBCBS
5691619OtherAETNA
MIRT810006OtherM CARE
100136OtherCARE CHOICES
MI366180OtherHAP
5691619OtherAETNA