Provider Demographics
NPI:1164452074
Name:PURUSOTHAMAN, VINOTH (PT)
Entity Type:Individual
Prefix:MR
First Name:VINOTH
Middle Name:
Last Name:PURUSOTHAMAN
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 1:25865 W 12 MILE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1817
Mailing Address - Country:US
Mailing Address - Phone:248-208-7492
Mailing Address - Fax:248-208-7494
Practice Address - Street 1:25865 12 MILE RD
Practice Address - Street 2:SUITE 116
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034
Practice Address - Country:US
Practice Address - Phone:248-208-7492
Practice Address - Fax:248-208-7494
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F323880OtherBCBS OF MI
MI0N92060001Medicare PIN