Provider Demographics
NPI:1205925328
Name:ALTENBURG, MICHAEL REED (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:REED
Last Name:ALTENBURG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29275 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 150
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1044
Practice Address - Country:US
Practice Address - Phone:248-351-6300
Practice Address - Fax:248-351-9329
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F32941OtherBLUE CROSS BLUE SHIELD
MIMI6211126Medicare PIN
MI0F32941OtherBLUE CROSS BLUE SHIELD