Provider Demographics
NPI:1154510220
Name:STRIDE PHYSICAL THERAPY INC.,
Entity Type:Organization
Organization Name:STRIDE PHYSICAL THERAPY INC.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GANESHKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANMUGASUNDARAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:248-334-9003
Mailing Address - Street 1:43750 WOODWARD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5063
Mailing Address - Country:US
Mailing Address - Phone:248-334-9003
Mailing Address - Fax:248-334-9334
Practice Address - Street 1:43750 WOODWARD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5063
Practice Address - Country:US
Practice Address - Phone:248-334-9003
Practice Address - Fax:248-334-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009846261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N92460Medicare PIN