Provider Demographics
NPI:1659620706
Name:CHAKRAVARTY, SAURISH (PT)
Entity Type:Individual
Prefix:
First Name:SAURISH
Middle Name:
Last Name:CHAKRAVARTY
Suffix:
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 1:5500 AUTO CLUB DR STE 150
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2779
Mailing Address - Country:US
Mailing Address - Phone:313-982-8265
Mailing Address - Fax:
Practice Address - Street 1:3161 CHURCHHILL LN
Practice Address - Street 2:#3
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-4316
Practice Address - Country:US
Practice Address - Phone:989-397-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist