Provider Demographics
NPI:1619065521
Name:TRIPP, TERRANCE DAVID (MPT)
Entity Type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:DAVID
Last Name:TRIPP
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9230
Mailing Address - Country:US
Mailing Address - Phone:906-249-3897
Mailing Address - Fax:
Practice Address - Street 1:3135 US HIGHWAY 41 W
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-9494
Practice Address - Country:US
Practice Address - Phone:906-225-5900
Practice Address - Fax:906-225-5939
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650E210580OtherBLUE CROSS BLUE SHIELD
MI650E210580OtherBLUE CROSS BLUE SHIELD
MIP18780001Medicare PIN