Provider Demographics
NPI:1417432204
Name:FAIR, RAYMOND LEE
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:LEE
Last Name:FAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22475 SHEVINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2128
Mailing Address - Country:US
Mailing Address - Phone:313-575-6859
Mailing Address - Fax:
Practice Address - Street 1:16151 JAMES COUZENS FWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2821
Practice Address - Country:US
Practice Address - Phone:313-587-4979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty