Provider Demographics
NPI:1740578095
Name:JEEVANANDAM, KISHORE (PT)
Entity Type:Individual
Prefix:
First Name:KISHORE
Middle Name:
Last Name:JEEVANANDAM
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 1:4181 BRIGHTON LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-7202
Mailing Address - Country:US
Mailing Address - Phone:313-414-1042
Mailing Address - Fax:
Practice Address - Street 1:20319 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1411
Practice Address - Country:US
Practice Address - Phone:248-476-8911
Practice Address - Fax:248-476-8913
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN15300014Medicare PIN