Provider Demographics
NPI:1710193370
Name:PROFESSIONAL PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIKAS
Authorized Official - Middle Name:
Authorized Official - Last Name:AHLUWALIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:586-268-1929
Mailing Address - Street 1:31150 HOOVER RD STE C
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7618
Mailing Address - Country:US
Mailing Address - Phone:586-268-1929
Mailing Address - Fax:586-268-1933
Practice Address - Street 1:31150 HOOVER RD STE C
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7618
Practice Address - Country:US
Practice Address - Phone:586-268-1929
Practice Address - Fax:586-268-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50018892OtherHAP
MI104690994OtherMOLINA HMO
MI104690994Medicaid
MI650F357800OtherBCBSM
MI204258600OtherUS DEPT OF LABOR
MI=========OtherEIN COMMERCIAL
MI650F357800OtherBCBSM