Provider Demographics
NPI:1043591688
Name:SAMANTA, SUBHRANSU MOHAN (BPT)
Entity Type:Individual
Prefix:MR
First Name:SUBHRANSU
Middle Name:MOHAN
Last Name:SAMANTA
Suffix:
Gender:M
Credentials:BPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5066 TRUMPETER DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-353-9075
Mailing Address - Fax:
Practice Address - Street 1:5066 TRUMPETER DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5518
Practice Address - Country:US
Practice Address - Phone:269-353-9075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist