Provider Demographics
NPI:1710023916
Name:ADVANCED NEURO REHAB SERVICES
Entity Type:Organization
Organization Name:ADVANCED NEURO REHAB SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-548-6400
Mailing Address - Street 1:26635 WOODWARD AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1372
Mailing Address - Country:US
Mailing Address - Phone:248-548-6400
Mailing Address - Fax:248-548-8885
Practice Address - Street 1:26635 WOODWARD AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070
Practice Address - Country:US
Practice Address - Phone:248-548-6400
Practice Address - Fax:248-548-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIHP050806-43010508062251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4377860Medicaid
MI0M89910Medicare ID - Type Unspecified
MIA-58048Medicare UPIN
0M89910Medicare UPIN