Provider Demographics
NPI:1548564255
Name:PRUDHOMME, MICHAEL THOMAS (DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:PRUDHOMME
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13638 SIBLEY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7406
Mailing Address - Country:US
Mailing Address - Phone:734-288-3739
Mailing Address - Fax:
Practice Address - Street 1:13638 SIBLEY RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7406
Practice Address - Country:US
Practice Address - Phone:734-288-3739
Practice Address - Fax:734-288-3745
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010103912251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH28738OtherBCBSM PIN
MI7849001Medicare PIN