Provider Demographics
NPI:1730297839
Name:OBIRI, JOSHUA ABIODUN (BSC RPT)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:ABIODUN
Last Name:OBIRI
Suffix:
Gender:M
Credentials:BSC RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29757 WEXFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-4401
Mailing Address - Country:US
Mailing Address - Phone:313-515-6067
Mailing Address - Fax:
Practice Address - Street 1:5958 N CANTON CENTER RD STE 300
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2766
Practice Address - Country:US
Practice Address - Phone:734-212-5828
Practice Address - Fax:734-212-5827
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4693539Medicaid
MI65-0-H2-0226-0OtherBCBS
MIN83540001Medicare ID - Type Unspecified