Provider Demographics
NPI:1043496250
Name:PHYSICAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE, P.C.
Other - Org Name:JACK BELEN, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-365-6661
Mailing Address - Street 1:20307 W. 12 MILE
Mailing Address - Street 2:STE. 102
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-356-6661
Mailing Address - Fax:248-356-6619
Practice Address - Street 1:20307 W 12 MILE RD
Practice Address - Street 2:STE. 102
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5407
Practice Address - Country:US
Practice Address - Phone:248-356-6661
Practice Address - Fax:248-356-6619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI042374208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1552582Medicaid
MIB49014Medicare UPIN
MI1552582Medicaid