Provider Demographics
NPI:1114940426
Name:PANGBORN, HEIDI
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:PANGBORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18285 E 10 MILE RD
Practice Address - Street 2:STE.100
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5802
Practice Address - Country:US
Practice Address - Phone:586-774-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650H229330OtherBCBS
MIP25560008Medicare PIN
MIN71890023Medicare PIN