Provider Demographics
NPI:1568428548
Name:MIDDHA, AJAY (PT OCS MTC)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:
Last Name:MIDDHA
Suffix:
Gender:M
Credentials:PT OCS MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W WACKERLY ST STE 3600
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4714
Mailing Address - Country:US
Mailing Address - Phone:989-631-3570
Mailing Address - Fax:989-631-3275
Practice Address - Street 1:555 W WACKERLY ST STE 3600
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4714
Practice Address - Country:US
Practice Address - Phone:989-631-3570
Practice Address - Fax:989-631-3275
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4495640Medicaid
MIN75070001Medicare ID - Type Unspecified
MI4495640Medicaid
MIP00089225Medicare PIN