Provider Demographics
NPI:1336114537
Name:SPECIALISTS IN REHABILITATION MEDICINE PC
Entity Type:Organization
Organization Name:SPECIALISTS IN REHABILITATION MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-650-5861
Mailing Address - Street 1:1135 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 425
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1871
Mailing Address - Country:US
Mailing Address - Phone:248-650-5861
Mailing Address - Fax:248-650-5865
Practice Address - Street 1:1135 W UNIVERSITY DR
Practice Address - Street 2:SUITE 425
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1871
Practice Address - Country:US
Practice Address - Phone:248-650-5861
Practice Address - Fax:248-650-5865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052881208100000X
MI4301055982208100000X
MI4301066288208100000X
MI4301062365208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3183497Medicaid
MI3183503Medicaid
MI4183698Medicaid
MI4504201Medicaid
MIH03751Medicare UPIN
MIM15890Medicare ID - Type UnspecifiedSIRM GROUP
MI4183698Medicaid
MI3183497Medicaid
MI4504201Medicaid