Provider Demographics
NPI:1053301341
Name:PROGRESS PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:PROGRESS PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHIVAKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBBARAYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:989-345-4300
Mailing Address - Street 1:3076 NORTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739-9277
Mailing Address - Country:US
Mailing Address - Phone:989-728-0242
Mailing Address - Fax:989-728-1144
Practice Address - Street 1:3076 NORTHRIDGE RD
Practice Address - Street 2:
Practice Address - City:HALE
Practice Address - State:MI
Practice Address - Zip Code:48739-9277
Practice Address - Country:US
Practice Address - Phone:989-728-0242
Practice Address - Fax:989-728-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008794225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F510260OtherBCBSM
MI4621772Medicaid
MI4621772Medicaid
MI4621772Medicaid