Provider Demographics
NPI:1265603013
Name:PHYSICAL MEDICINE& REHABILITATION CONSULTANT AND PAIN MANAGEMENT,P.C.
Entity type:Organization
Organization Name:PHYSICAL MEDICINE& REHABILITATION CONSULTANT AND PAIN MANAGEMENT,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWIT
Authorized Official - Middle Name:
Authorized Official - Last Name:TEKLEHAIMANOT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-717-3816
Mailing Address - Street 1:21675 COOLIDGE HWY
Mailing Address - Street 2:STE A
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-3171
Mailing Address - Country:US
Mailing Address - Phone:248-546-3467
Mailing Address - Fax:248-546-3477
Practice Address - Street 1:21675 COOLIDGE HWY
Practice Address - Street 2:STE A
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-3171
Practice Address - Country:US
Practice Address - Phone:248-546-3467
Practice Address - Fax:248-546-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011761261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4493556Medicaid
MI4493556Medicaid
MIG36510Medicare UPIN