Provider Demographics
NPI:1407058209
Name:ORTHOPEDIC PHYSICAL THERAPY SPECIALIST LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC PHYSICAL THERAPY SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:269-637-9099
Mailing Address - Street 1:02957 73RD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9364
Mailing Address - Country:US
Mailing Address - Phone:269-637-9099
Mailing Address - Fax:269-637-9224
Practice Address - Street 1:02957 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9364
Practice Address - Country:US
Practice Address - Phone:269-637-9099
Practice Address - Fax:269-637-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011004261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4800853-10Medicaid
MIOPO2050Medicare PIN