Provider Demographics
NPI:1205865318
Name:GREATER DETROIT PHYSICAL THERAPY & REHABILITATION PC
Entity type:Organization
Organization Name:GREATER DETROIT PHYSICAL THERAPY & REHABILITATION PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARAN
Authorized Official - Middle Name:JONATHON
Authorized Official - Last Name:LERNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-721-0011
Mailing Address - Street 1:1678 S MERRIMAN RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5355
Mailing Address - Country:US
Mailing Address - Phone:734-721-0011
Mailing Address - Fax:734-721-0859
Practice Address - Street 1:1678 S MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5355
Practice Address - Country:US
Practice Address - Phone:734-721-0011
Practice Address - Fax:734-721-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL65648884345959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3128216Medicaid
MI700H213850OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI3128216Medicaid
FO7596Medicare UPIN
MI700H213850OtherBLUE CROSS BLUE SHIELD OF MICHIGAN