Provider Demographics
NPI:1851764666
Name:MIDLAND PHYSICAL THERAPY SPORTS REHAB
Entity Type:Organization
Organization Name:MIDLAND PHYSICAL THERAPY SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-341-1070
Mailing Address - Street 1:4710 EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2606
Mailing Address - Country:US
Mailing Address - Phone:989-341-1070
Mailing Address - Fax:989-341-1072
Practice Address - Street 1:4710 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2606
Practice Address - Country:US
Practice Address - Phone:989-341-1070
Practice Address - Fax:989-341-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty