Provider Demographics
NPI:1467480533
Name:DAVIDSON, STEVEN NORRIS (PT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:NORRIS
Last Name:DAVIDSON
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 1:7776 WHITBURN DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 5TH ST NW
Practice Address - Street 2:SUITE 404
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5219
Practice Address - Country:US
Practice Address - Phone:616-356-5000
Practice Address - Fax:616-356-5001
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501300242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP04810001Medicare ID - Type UnspecifiedWPS MEDICARE
MI0P04810Medicare PIN