Provider Demographics
NPI:1326196650
Name:MENDELSON ORTHOPEDIC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MENDELSON ORTHOPEDIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-542-0200
Mailing Address - Street 1:14555 LEVAN RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5083
Mailing Address - Country:US
Mailing Address - Phone:734-542-0200
Mailing Address - Fax:
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 215
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-542-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2020755Medicaid
MIB43431Medicare UPIN
MI2020755Medicaid