Provider Demographics
NPI:1598783854
Name:JOSEPH, PROMODH (PT)
Entity Type:Individual
Prefix:MR
First Name:PROMODH
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7762 NORTH FEDERAL RD
Mailing Address - Street 2:P.O.BOX 256
Mailing Address - City:HOWARD CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49329
Mailing Address - Country:US
Mailing Address - Phone:231-937-8485
Mailing Address - Fax:231-937-9836
Practice Address - Street 1:7762 NORTH FEDERAL RD
Practice Address - Street 2:
Practice Address - City:HOWARD CITY
Practice Address - State:MI
Practice Address - Zip Code:49329
Practice Address - Country:US
Practice Address - Phone:231-937-8485
Practice Address - Fax:231-937-9836
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650E900140OtherBCBS PROVIDERNUMBER
MI0P18050Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER