Provider Demographics
NPI:1811011521
Name:PHYSICAL MEDICINE & REHABILITATION SPECIALISTS PC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE & REHABILITATION SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-247-4444
Mailing Address - Street 1:53760 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1539
Mailing Address - Country:US
Mailing Address - Phone:574-247-4444
Mailing Address - Fax:574-243-5555
Practice Address - Street 1:53760 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1539
Practice Address - Country:US
Practice Address - Phone:574-247-4444
Practice Address - Fax:574-243-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50003415A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200296450AMedicaid
IN167420Medicare PIN
IN200580Medicare PIN