Provider Demographics
NPI:1780857870
Name:VINSON, RYAN DAVID (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:VINSON
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 1:878 S ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2740
Mailing Address - Country:US
Mailing Address - Phone:248-601-9207
Mailing Address - Fax:
Practice Address - Street 1:23211 21 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042
Practice Address - Country:US
Practice Address - Phone:586-231-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
650E026820OtherBLUE CROSS BLUE SHIELD
MIMI359002Medicare PIN