Provider Demographics
NPI:1417428384
Name:MOHAMMAD, PERCIVAL U (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:PERCIVAL
Middle Name:U
Last Name:MOHAMMAD
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9904 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1691
Mailing Address - Country:US
Mailing Address - Phone:734-558-2838
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3258
Practice Address - Country:US
Practice Address - Phone:734-343-7500
Practice Address - Fax:734-343-7501
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501004612Medicaid