Provider Demographics
NPI:1043240211
Name:VIG, MIKE (PT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:VIG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 ROY ST
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1138
Mailing Address - Country:US
Mailing Address - Phone:320-830-4271
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:616 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1380
Practice Address - Country:US
Practice Address - Phone:320-585-5395
Practice Address - Fax:320-839-4196
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7202225100000X
SD0736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650000990Medicare PIN