Provider Demographics
NPI:1548764566
Name:MATHEW JACOB, BINU
Entity Type:Individual
Prefix:
First Name:BINU
Middle Name:
Last Name:MATHEW JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6868 REDFORD CIR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1202
Mailing Address - Country:US
Mailing Address - Phone:586-879-7667
Mailing Address - Fax:
Practice Address - Street 1:6868 REDFORD CIR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1202
Practice Address - Country:US
Practice Address - Phone:586-879-7667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist