Provider Demographics
NPI:1548428626
Name:MUNGER PHYSICAL THERAPY, PLC
Entity Type:Organization
Organization Name:MUNGER PHYSICAL THERAPY, PLC
Other - Org Name:MUNGER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARKUS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:810-385-7405
Mailing Address - Street 1:4351 24TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4506
Mailing Address - Country:US
Mailing Address - Phone:810-385-7405
Mailing Address - Fax:810-385-7420
Practice Address - Street 1:4351 24TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4506
Practice Address - Country:US
Practice Address - Phone:810-385-7405
Practice Address - Fax:810-385-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004051261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65-0-G4-1223-0OtherBLUE CROSS AND BLUS SHIELD OF MICHIGAN
MI0P57470Medicare PIN