Provider Demographics
NPI:1801016969
Name:GILL, SAMUEL (PT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GILL
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 1:44125 W. TWELVE MILE ROAD
Mailing Address - Street 2:E-123
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377
Mailing Address - Country:US
Mailing Address - Phone:248-952-4340
Mailing Address - Fax:248-465-6059
Practice Address - Street 1:1096 S BELSAY RD
Practice Address - Street 2:STE G
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-743-1611
Practice Address - Fax:810-249-4230
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010095892251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic