Provider Demographics
NPI:1518224013
Name:MICHIGAN ORTHOPAEDIC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MICHIGAN ORTHOPAEDIC PHYSICAL THERAPY
Other - Org Name:MICHIGAN HAND THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:WIATER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MBA
Authorized Official - Phone:248-566-3525
Mailing Address - Street 1:4401 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6516
Mailing Address - Country:US
Mailing Address - Phone:248-566-3525
Mailing Address - Fax:248-566-3527
Practice Address - Street 1:4401 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6516
Practice Address - Country:US
Practice Address - Phone:248-566-3525
Practice Address - Fax:248-566-3527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI5501015108261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6740100001Medicare NSC
MIMI5935Medicare PIN