Provider Demographics
NPI:1700014024
Name:THORN, MICHAEL LEWIS (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEWIS
Last Name:THORN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7616
Mailing Address - Country:US
Mailing Address - Phone:330-433-1200
Mailing Address - Fax:330-433-1596
Practice Address - Street 1:6046 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7616
Practice Address - Country:US
Practice Address - Phone:330-433-1200
Practice Address - Fax:330-433-1596
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTH4266762Medicare PIN
OHTH4266761Medicare PIN