Provider Demographics
NPI:1659371417
Name:CARSON, GEORGE PURDY III (PT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:PURDY
Last Name:CARSON
Suffix:III
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 1:53 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6433
Mailing Address - Country:US
Mailing Address - Phone:248-236-0035
Mailing Address - Fax:248-236-0125
Practice Address - Street 1:53 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6433
Practice Address - Country:US
Practice Address - Phone:248-236-0035
Practice Address - Fax:248-236-0125
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501300664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN96240001Medicare PIN