Provider Demographics
NPI:1659384626
Name:PROFESSIONAL PHYSICAL THERAPY CLINIC INC
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHANMUGAVELU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:313-945-9380
Mailing Address - Street 1:13530 MICHIGAN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-945-9380
Mailing Address - Fax:313-945-9184
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-945-9380
Practice Address - Fax:313-945-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON99910Medicare ID - Type Unspecified