Provider Demographics
NPI:1376771287
Name:MARQUETTE REHABILITATION & SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:MARQUETTE REHABILITATION & SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIPLIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:906-362-0013
Mailing Address - Street 1:1455 W FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2654
Mailing Address - Country:US
Mailing Address - Phone:906-226-0574
Mailing Address - Fax:888-347-1135
Practice Address - Street 1:1455 W FAIR AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2654
Practice Address - Country:US
Practice Address - Phone:906-226-0574
Practice Address - Fax:888-347-1135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013363261QP2000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDT4588OtherRAILROAD MEDICARE PTAN
MI1376771287Medicaid
MI1376771287Medicaid