Provider Demographics
NPI:1003993312
Name:CENTER FOR PHYSICAL MEDICINE & REHABILITATION PC
Entity Type:Organization
Organization Name:CENTER FOR PHYSICAL MEDICINE & REHABILITATION PC
Other - Org Name:TEAM WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-552-4499
Mailing Address - Street 1:13850 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3730
Mailing Address - Country:US
Mailing Address - Phone:586-552-4499
Mailing Address - Fax:586-552-4878
Practice Address - Street 1:13850 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3730
Practice Address - Country:US
Practice Address - Phone:586-552-4499
Practice Address - Fax:586-552-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2024-03-26
Deactivation Date:2023-08-01
Deactivation Code:
Reactivation Date:2023-09-05
Provider Licenses
StateLicense IDTaxonomies
MI174400000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5916040001Medicare NSC
MI5916040001Medicare NSC