Provider Demographics
NPI:1568602050
Name:VISITING HOME MD
Entity Type:Organization
Organization Name:VISITING HOME MD
Other - Org Name:PHYSICAL MEDICINE AND REHABILITATION SPECIALISTS OF MICHIGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUVENAL
Authorized Official - Middle Name:LIPANA
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-350-8463
Mailing Address - Street 1:9245 AUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-6403
Mailing Address - Country:US
Mailing Address - Phone:917-816-4427
Mailing Address - Fax:269-382-4808
Practice Address - Street 1:4239 ISABELLE ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1770
Practice Address - Country:US
Practice Address - Phone:269-350-8463
Practice Address - Fax:269-382-4808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087182208100000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII59129Medicare UPIN