Provider Demographics
NPI:1619094034
Name:BOSE, SUJOY (PT)
Entity Type:Individual
Prefix:MR
First Name:SUJOY
Middle Name:
Last Name:BOSE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:SUJOY
Other - Middle Name:
Other - Last Name:BASU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:27172 LILLY DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2796
Mailing Address - Country:US
Mailing Address - Phone:734-676-2669
Mailing Address - Fax:734-676-2655
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:734-216-2669
Practice Address - Fax:313-966-0065
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007326225100000X, 2251C2600X, 2251N0400X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonary
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic