Provider Demographics
NPI:1083686596
Name:PYRAMIDAL REHAB, PC
Entity Type:Organization
Organization Name:PYRAMIDAL REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANSOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-225-7740
Mailing Address - Street 1:2837 US HIGHWAY 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082652208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2505210422OtherBLUE CROSS BLUE SHIELD MI
MI104603246Medicaid
MIH96933Medicare UPIN
DC1554Medicare PIN
MI104603246Medicaid