Provider Demographics
NPI:1295332435
Name:ELITE PHYSICAL THERAPY OF SOUTHFIELD LLC
Entity type:Organization
Organization Name:ELITE PHYSICAL THERAPY OF SOUTHFIELD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVINDARAJALU
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:248-722-1156
Mailing Address - Street 1:15565 NORTHLAND DR E STE 816
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5329
Mailing Address - Country:US
Mailing Address - Phone:248-722-1156
Mailing Address - Fax:
Practice Address - Street 1:15565 NORTHLAND DR E STE 816
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5329
Practice Address - Country:US
Practice Address - Phone:248-722-1156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
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
MIPENDINGMedicaid