Provider Demographics
NPI:1093712192
Name:PRZYBYSZ, ROBERT ANDREW (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ANDREW
Last Name:PRZYBYSZ
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 1:335 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2118
Mailing Address - Country:US
Mailing Address - Phone:616-392-3363
Mailing Address - Fax:616-392-9030
Practice Address - Street 1:335 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2118
Practice Address - Country:US
Practice Address - Phone:616-392-3363
Practice Address - Fax:616-392-9030
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ03103Medicare UPIN
MI0N81330Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MI650D113260OtherBLUE CROSS BLUE SHIELD ID
MIQ03103Medicare UPIN
MI200223019OtherTAX ID
MIRP002594OtherLICENSE NUMBER
MIN81330003Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER