Provider Demographics
NPI:1891702106
Name:SOMERVILLE, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SOMERVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 MAYER RD APT M252
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-2007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 KINGSLEY CT
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1270
Practice Address - Country:US
Practice Address - Phone:989-652-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDD5657OtherRAILROAD
MI650G312140OtherBLUE CROSS BLUE SHIELD MI
MIDD5657OtherRAILROAD
MI650G312140OtherBLUE CROSS BLUE SHIELD MI