Provider Demographics
NPI:1114006863
Name:HEMINGWAY, BRYAN (MPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HEMINGWAY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 N M 37 HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-8166
Mailing Address - Country:US
Mailing Address - Phone:269-795-4230
Mailing Address - Fax:269-795-4191
Practice Address - Street 1:4525 N M 37 HWY
Practice Address - Street 2:SUITE B
Practice Address - City:MIDDLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:49333-8166
Practice Address - Country:US
Practice Address - Phone:269-795-4230
Practice Address - Fax:269-795-4191
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650Z810240OtherBC/BS
MI650Z810240OtherBC/BS
MI0P56980Medicare PIN