Provider Demographics
NPI:1427229921
Name:ST MARY PHYSICAL THERAPY AND REHABILITATION LLC
Entity Type:Organization
Organization Name:ST MARY PHYSICAL THERAPY AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:FALTAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-739-9059
Mailing Address - Street 1:11258 REGAL DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4974
Mailing Address - Country:US
Mailing Address - Phone:248-739-9059
Mailing Address - Fax:
Practice Address - Street 1:20825 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1485
Practice Address - Country:US
Practice Address - Phone:248-739-9059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008309261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F329970OtherBLUE SHIELD OF MICHIGAN
MI0P29910Medicare PIN