Provider Demographics
NPI:1023505062
Name:RANCOUR, CHARLOTTE BLAIR (PTA)
Entity type:Individual
Prefix:MISS
First Name:CHARLOTTE
Middle Name:BLAIR
Last Name:RANCOUR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:CHARLOTTE
Other - Middle Name:BLAIR
Other - Last Name:RANCOUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:515 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4316
Mailing Address - Country:US
Mailing Address - Phone:517-583-2853
Mailing Address - Fax:
Practice Address - Street 1:515 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4316
Practice Address - Country:US
Practice Address - Phone:989-798-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003992208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJXP913029551OtherBLUE CROSS BLUE SHIELD