Provider Demographics
NPI:1477097590
Name:JADAV, SAMARTH
Entity Type:Individual
Prefix:
First Name:SAMARTH
Middle Name:
Last Name:JADAV
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 1:2652 BEACON HILL DR APT 207
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-3729
Mailing Address - Country:US
Mailing Address - Phone:248-325-4710
Mailing Address - Fax:
Practice Address - Street 1:20755 GREENFIELD RD STE 602
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5409
Practice Address - Country:US
Practice Address - Phone:248-443-8088
Practice Address - Fax:248-443-8099
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist