Provider Demographics
NPI:1396039541
Name:KLOBUCHER, MICHAEL JAMES (PT, DPT, OCS, CMPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:KLOBUCHER
Suffix:
Gender:M
Credentials:PT, DPT, OCS, CMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 S MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1286
Mailing Address - Country:US
Mailing Address - Phone:616-866-8084
Mailing Address - Fax:616-866-8085
Practice Address - Street 1:65 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1286
Practice Address - Country:US
Practice Address - Phone:616-866-8084
Practice Address - Fax:616-866-8085
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P14760019Medicare PIN