Provider Demographics
NPI:1134240658
Name:MID MICHIGAN PHYSICAL THERAPY SPECIALISTS, LLC
Entity type:Organization
Organization Name:MID MICHIGAN PHYSICAL THERAPY SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAINES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, M ED, OCS
Authorized Official - Phone:517-223-8308
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-0323
Mailing Address - Country:US
Mailing Address - Phone:517-223-8308
Mailing Address - Fax:517-223-8344
Practice Address - Street 1:125 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-5137
Practice Address - Country:US
Practice Address - Phone:517-223-8308
Practice Address - Fax:517-223-8344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2015-07-27
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
MI0P22890Medicare PIN