Provider Demographics
NPI:1477664746
Name:HAMER, GAVIN EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:EDWARD
Last Name:HAMER
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 1:14555 LEVAN RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5083
Mailing Address - Country:US
Mailing Address - Phone:734-464-0400
Mailing Address - Fax:734-464-0404
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 116
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-464-0400
Practice Address - Fax:734-464-0404
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65-0H2-2419-0Medicare ID - Type Unspecified