Provider Demographics
NPI:1104033182
Name:REHAB SPECIALISTS OF SOUTHFIELD
Entity Type:Organization
Organization Name:REHAB SPECIALISTS OF SOUTHFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-353-7507
Mailing Address - Street 1:4777 ATKINS RD
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:MI
Mailing Address - Zip Code:48049-4507
Mailing Address - Country:US
Mailing Address - Phone:248-353-7507
Mailing Address - Fax:
Practice Address - Street 1:29355 NORTHWESTERN HWY
Practice Address - Street 2:#200
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1053
Practice Address - Country:US
Practice Address - Phone:248-353-7507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501001690OtherLICENSE