Provider Demographics
NPI:1164648432
Name:CENTER FOR SPORTS MEDICINE & FITNESS, INC.
Entity Type:Organization
Organization Name:CENTER FOR SPORTS MEDICINE & FITNESS, INC.
Other - Org Name:PROCARE PHYSICAL THERAPY & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIVEK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRISHKAR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-353-3260
Mailing Address - Street 1:18535 W 12 MILE RD STE B
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2664
Mailing Address - Country:US
Mailing Address - Phone:248-353-3260
Mailing Address - Fax:888-267-1867
Practice Address - Street 1:18535 W 12 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2664
Practice Address - Country:US
Practice Address - Phone:248-353-3260
Practice Address - Fax:888-267-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30499OtherBCBSM
MI30383BOtherBCBS
23-6645Medicare UPIN