Provider Demographics
NPI:1942387733
Name:NORTHSPORT PHYSICAL THERAPY & REHABILITATION P C
Entity Type:Organization
Organization Name:NORTHSPORT PHYSICAL THERAPY & REHABILITATION P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-731-1777
Mailing Address - Street 1:1622 DICKERSON RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9206
Mailing Address - Country:US
Mailing Address - Phone:989-731-1777
Mailing Address - Fax:989-731-1166
Practice Address - Street 1:1622 DICKERSON RD
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9206
Practice Address - Country:US
Practice Address - Phone:989-731-1777
Practice Address - Fax:989-731-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236698Medicare PIN