Provider Demographics
NPI:1326184151
Name:DERY PHYSICAL THERAPY SERVICES, PC
Entity Type:Organization
Organization Name:DERY PHYSICAL THERAPY SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CASIMIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:KILYANEK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-897-7055
Mailing Address - Street 1:901 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-1581
Mailing Address - Country:US
Mailing Address - Phone:616-897-7055
Mailing Address - Fax:616-897-7366
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1581
Practice Address - Country:US
Practice Address - Phone:616-897-7055
Practice Address - Fax:616-897-7366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30732OtherBCSBM NUMBER
MI30732OtherBCSBM NUMBER