Provider Demographics
NPI:1033187604
Name:KONOZA, MICHAEL GEORGE (MSPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:KONOZA
Suffix:
Gender:M
Credentials:MSPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 ASHDALE DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-2517
Mailing Address - Country:US
Mailing Address - Phone:843-522-2909
Mailing Address - Fax:843-521-0908
Practice Address - Street 1:1076 RIBAUT RD
Practice Address - Street 2:SUITE102
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5476
Practice Address - Country:US
Practice Address - Phone:843-521-1970
Practice Address - Fax:843-521-0908
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ337307754Medicare PIN