Provider Demographics
NPI:1417251265
Name:METRO PHYSICAL THERAPY
Entity Type:Organization
Organization Name:METRO PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIK
Authorized Official - Middle Name:
Authorized Official - Last Name:OLEKSY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-546-8005
Mailing Address - Street 1:28035 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2858
Mailing Address - Country:US
Mailing Address - Phone:248-546-8005
Mailing Address - Fax:248-546-8115
Practice Address - Street 1:28035 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2858
Practice Address - Country:US
Practice Address - Phone:248-546-8005
Practice Address - Fax:248-546-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4315Medicare UPIN