Provider Demographics
NPI:1275619538
Name:ELY, JON DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:DAVID
Last Name:ELY
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:5590 MAIN STREET , SUITE 4
Mailing Address - City:LEXINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48450-0416
Mailing Address - Country:US
Mailing Address - Phone:810-359-8700
Mailing Address - Fax:810-359-8702
Practice Address - Street 1:5590 MAIN ST.
Practice Address - Street 2:SUITE 4
Practice Address - City:LEXINGTON
Practice Address - State:MI
Practice Address - Zip Code:48450
Practice Address - Country:US
Practice Address - Phone:810-359-8700
Practice Address - Fax:810-359-8702
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5501008405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP24960002Medicare ID - Type Unspecified