Provider Demographics
NPI:1861502882
Name:SKINNER, BRADFORD T (MPT,DIP,MDT,OCS)
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:T
Last Name:SKINNER
Suffix:
Gender:M
Credentials:MPT,DIP,MDT,OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5700 JACKSON RD
Practice Address - Street 2:STE B
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9504
Practice Address - Country:US
Practice Address - Phone:734-926-4710
Practice Address - Fax:734-926-4712
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750038Medicare PIN
MIMI6211008Medicare PIN