Provider Demographics
NPI:1205863743
Name:MID-MICHIGAN PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MID-MICHIGAN PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC
Other - Org Name:PHYSICAL THERAPY & REHAB SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDHA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:989-631-3570
Mailing Address - Street 1:555 W WACKERLY ST STE 3600
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4714
Mailing Address - Country:US
Mailing Address - Phone:989-631-3570
Mailing Address - Fax:989-631-3275
Practice Address - Street 1:555 W WACKERLY ST STE 3600
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4714
Practice Address - Country:US
Practice Address - Phone:989-631-3570
Practice Address - Fax:989-631-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X
5501006768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDB1417OtherRETIRED RAILROAD MEDICARE
MIDB1417OtherRETIRED RAILROAD MEDICARE
MI0N75070Medicare ID - Type Unspecified
MIDB1417Medicare UPIN
MI5179300001Medicare NSC