Provider Demographics
NPI:1164477121
Name:FATE, ANDREW JOSEPH (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:FATE
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1908 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1232
Mailing Address - Country:US
Mailing Address - Phone:269-459-6212
Mailing Address - Fax:269-585-6068
Practice Address - Street 1:1908 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1232
Practice Address - Country:US
Practice Address - Phone:269-459-6212
Practice Address - Fax:269-585-6068
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP29310001Medicare ID - Type UnspecifiedPART B PROVIDER #