Provider Demographics
NPI:1417179367
Name:SAMSON, RANJITH (PT)
Entity Type:Individual
Prefix:
First Name:RANJITH
Middle Name:
Last Name:SAMSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 S MAIN ST
Mailing Address - Street 2:PO BOX 158
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251-0158
Mailing Address - Country:US
Mailing Address - Phone:517-589-9050
Mailing Address - Fax:517-589-9059
Practice Address - Street 1:148 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-2561
Practice Address - Country:US
Practice Address - Phone:517-589-9050
Practice Address - Fax:517-589-9059
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5503012063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI562460025OtherTAX ID
MA5503012063OtherSTATE LIC
MI650C811890OtherBLUE CROSS
MI650C811890OtherBLUE CROSS
MIN77640005Medicare PIN
MI562460025OtherTAX ID
MA5503012063OtherSTATE LIC
MIN97480004Medicare PIN