Provider Demographics
NPI: | 1508848318 |
---|---|
Name: | MARY FREE BED REHABILITATION, L.L.C |
Entity Type: | Organization |
Organization Name: | MARY FREE BED REHABILITATION, L.L.C |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RANDALL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DENEFF |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 616-840-8317 |
Mailing Address - Street 1: | 1845 LIVERNOIS RD |
Mailing Address - Street 2: | |
Mailing Address - City: | TROY |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48083-1731 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 248-362-2150 |
Mailing Address - Fax: | 248-362-1702 |
Practice Address - Street 1: | 1845 LIVERNOIS RD |
Practice Address - Street 2: | |
Practice Address - City: | TROY |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48083-1731 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-362-2150 |
Practice Address - Fax: | 248-362-1702 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-11-17 |
Last Update Date: | 2020-08-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 01686 | 225100000X, 2251G0304X, 2251H1200X, 2251N0400X, 2251P0200X, 2251S0007X, 2251X0800X |
MI | 5201002959 | 225X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Single Specialty | |
No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | Group - Single Specialty |
No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | Group - Single Specialty |
No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology | Group - Single Specialty |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Single Specialty |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | Group - Single Specialty |
No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Single Specialty |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 4669868 | Other | AETNA |
MI | 89046A | Other | HAP |
MI | 30688 | Other | BCBSM |
MI | 16854 | Other | MCARE |
MI | 134812400 | Other | US DEPT OF LABOR |
MI | 382473857 | Other | PPOM |
MI | P459578 | Other | BLUE CHOICE |