Provider Demographics
NPI:1609035450
Name:PUTVIN, BRADLEY EDWARD (PT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:EDWARD
Last Name:PUTVIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:27733 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6641
Mailing Address - Country:US
Mailing Address - Phone:810-923-2361
Mailing Address - Fax:586-427-6642
Practice Address - Street 1:5889 WHITMORE LAKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1998
Practice Address - Country:US
Practice Address - Phone:810-229-7931
Practice Address - Fax:810-229-7935
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501001469OtherLICENSE
PENDINGMedicare PIN